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Full text of "Differential diagnosis presented through an analysis of 385 cases"

1bar\mrO mntverstt? 

Xfbrars of 
TEbe /lOefctcal School 




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^Harvard Medical Library 
in the Francis A. Countway 
Library of Medicine -Boston 



VERITATEM PERMEDICIJSfAM QU/ERAfAVS 



Differential Diagnosis 



PRESENTED THROUGH 
AN ANALYSIS OF 385 CASES 



By 



RICHARD C. CABOT, M.D. 

ASSISTANT PROFESSOR OF CLINICAL MEDICINE, HARVARD UNIVERSITY MEDICAL SCHOOL, BOSTON 



VOLUME 



SECOND EDITION, REVISED 
PRO FUSEL Y ILL USTRA TED 



I* u 1 1 \!>»r l-ili \ • \ l> i ONDON 



W. B. SAUNDERS COMPANY 




A 



Copyright, 1911, by W. B. Saunders Company. Reprinted March, 1911, June, 1911, and October, 1911 
Revised, reprinted, and recopyrighted February, 1912. Reprinted October, 1912, January, 1913, 

and July, 1913 



Copyright, 1912, by W. B. Saunders Company 



Reprinted February, 1914 



PRINTED IN AMERICA 



PRE88 OF 

W. B. 8AUNOER8 COMPANY 

PHILADELPHIA 



PREFACE TO THE SECOND EDITION 



I have corrected some typographical errors kindly pointed out by 
correspondents, reorganized the index and table of contents, and 
made a few more material changes. Two new cases are introduced: 
one by the kind permission of Dr. Frederick J. Bowen of Mount 
Morris, N. Y., whom I take this opportunity of thanking. 

Some of the symptoms not treated in this volume (e. g., hema- 
turia, edema, diarrhea, dyspepsia, glandular enlargement, etc.) will 
be dealt with in a second volume along the same lines. 



PREFACE 



The attempt to make and defend a differential diagnosis brings 
all one's failings into sharp relief. Though I have done my best to 
avoid obvious errors in this book, I am confident that it contains 
much that deserves — and I hope will receive — challenge from other 
physicians. 

My best thanks are due to Dr. James H. Young for help in the 
diagrams, and to my secretary, Miss Edith K. Richie, who has made 
the index and rendered many invaluable services throughout the 
preparation of the book. 

190 Marlborough St., Boston, Mass. 



TABLE OF CONTENTS 



INTRODUCTION Page 

The Presenting Symptom I j 

The Grouping of Reasonable Possibilities 17 

Advantages of the Plan Here Adopted j& 

Limits I9 

Vulnerability of All Differential Diagnosis 19 

Omissions 21 

Explanation of Diagrams and Charts 22 

CHAPTER I 

PAIN 

General Considerations 24 

Degree of Pain 25 

Types of Pain 26 

Relation of Pain to Other Facts 27 

Habit Pains 29 

Theories Regarding the Production of Pain 29 

CHAPTER II 

HEADACHE 

General Considerations 32 

Position and Nature of the Headache 37 

Two Traditional Fallacies About Headache 38 

Important Tests 39 

Case Xo. 

1 . Methemoglobinemia 39 

2. Syphilitic Periostitis 41 

3. Syphilis 43 

4. Syphilis 45 

5. Heada< he of Psy< hit Origin 47 

6. Urcmii Headache; Chronic Glomerulonephritis; Graves' Disease 49 

7. Typhoid Fever 52 

8. Fracture of the Base of Skull 54 

0. Sinusitis 55 

10. Miliary Tuben 111 s'» 

11. Stone in the Kidney with VbsceSfl and Nephritis 

12. Malaria 00 

P I Tachycardia Complicating a Chroni< Myocardial Insufficiency . 61 

14. Postpneumonic Empyi ms 63 

B 



6 TABLE OF CONTENTS 

Case No. Page 

15. Staphylococcus Infection (Osteomyelitis) 65 

16. Dementia Paralytica 67 

17. Headache of Unknown Origin 68 

18. Meningitis 69 

19. Sinusitis 71 

20. Typhoid Fever 73 

21. Miliary Tuberculosis 74 

22. Cerebral Hemorrhage 76 

CHAPTER III 

LUMBAR PAIN 

Examination of Patients with Lumbar Pain 87 

Case No. 

23. Tuberculous Pneumothorax 87 

24. Hypertrophic Spinal Arthritis 89 

25. Typhoid Fever 91 

26. Appendicitis; Herpes Zoster . 93 

27. Unknown Infection 95 

28. Sacro-iliac Strain 96 

29. Sacro-iliac Strain . 97 

30. Renal Infection, Hematogenous or Ascending 98 

31. Pneumonia 100 

32. Debility 101 

33. Typhoid and Colon Bacillus Infection 103 

34. Neuritis ; ' . . 105 

35. Infectious Spondylitis 107 

36. Vertebral Tuberculosis 108 

37. Aortic Aneurysm 109 

38. Lumbago (?); Infectious Spondylitis (?) no 

39. Renal Stone; Multiple Renal Abscess in 

40. Gall-stones " 113 

41. Retroperitoneal Sarcoma 114 

42. Typhoidal Spondylitis 115 

43. Spinal Tuberculosis 117 

44. Old Syphilis; Acute Spondylitis 118 

45. Renal Stone 119 

46. Debility 1 20 

47. Streptococcus Meningitis 121 

48. Prolapsed, Retroverted, Incarcerated, Pregnant Uterus 122 

49. Parturition 1 23 

49a. Tetanus 1 24 

CHAPTER IV 
GENERAL ABDOMINAL PAIN 

Cask No. 

50. Neurosis; Mucous Colitis 128 

51. Had Hygiene 132 

5a. Constipation 133 

53. Peritonea] Tuberculosis 134 

54. Postoperative Neurosis 136 



TABLE OF CONTENTS 7 

Case No. Pace 

55. Typhoid Fever 137 

Neurosis 139 

Lead Poisoning 140 

I )ynamic Aorta 141 

59. Acute ( rastro-enteritis 143 

60. Cancer of the Stomach 144 

61. Recurrent Intestinal Cancer 146 

62. Tertian Malaria 148 

63. Perforative Colitis and ( ieneral Peritonitis 149 

64. Cancer of the Rectum 1 50 

65. Obstruction of the Intestine; Volvulus 151 

CHAPTER V 

EPIGASTRIC PAIN 
Case No. 

66. Hepatic Gumma; Syphilis 1 54 

67. Plumbism 157 

68. Constipation 1 5q 

69. Chlorosis 1 60 

70. Tabes Dorsalis 161 

71. Gastric Neurosis 162 

72. Duodenal Ulcer 163 

73. Gall-stones 165 

74. Hyperchlorhydria (Alcoholism ?) [67 

75. Angina Pectoris (Low) 168 

76. Plumbism 160 

77. Sarcoma Testis with Metastases • 171 

78. Tuberculous Peritonitis 1 7 2 

79. Constipation 173 

80. Pyloric Adhesions . 174 

81. Cholelithiasis and Gangrenous Gall-bladder 1 70 

82. Cholelithiasis with Perforations 178 

83. Acute Pericarditis 1 70 

84. Arteriosclerosis; Vascular ( Irises [81 

85. Pericarditis [83 

86. Gastric Cancer ' 1S4 

87. Pancreatic Cancer (Chronic Pancreatitis ? [86 

88. Gastrii Ulcer 187 

89. Ga-tric Neurosis [89 

(>o. Gastrii Neurosis 100 
or. AN oholism 

Melani holia [93 

93. Hepati. Congestion Uncompensated Valvular Heart Disease) 195 

94. Gall stones 107 

95. Gall -torn- [98 

CHAI'I l.k VI 
RIGH 1 HYPO HONDR] \< PAIN 

96. Peril ardial Effusion 

1 St our .'O8 



TABLE OF CONTENTS 

Case No. Page 

98. Catarrhal Jaundice 210 

99. Hepatic Cancer .< 211 

100. Alcoholic Gastritis 214 

101. Fibrous Endocarditis of the Mitral and Aortic Valves, with Insufficiency 

of Both 215 

102. Phthisis 217 

103. Acute Cholecystitis 219 

104. Hepatic Syphilis 220 

105. Hangebauch 222 

106. Stone in Ductus Choledochus 224 

107. Debility; Floating Kidney 225 

108. Debility 227 

109. Subdiaphragmatic Abscess 229 

1 10. Pancreatic Cancer 230 

in. Pericecal Tuberculosis 233 

112. Duodenal Ulcer (Local Peritonitis) 234 

113. Hysteria Minor 236 

114. Cholecystitis Complicating Typhoid Fever 238 



CHAPTER VII 

PAIN IN THE LEFT HYPOCHONDRIUM 

Case No. 

115. Pyonephrosis with Stone 242 

116. Functional Angina Pectoris 243 

117. Congenital Cystic Kidneys 246 

118. Myeloid Leukemia 247 

1 19. Renal Infection 250 

1 20. Hyperchlorhydria 251 

121. Renal Stone 253 

122. Hypernephroma 255 

1 23. Tuberculous Enteritis 256 



CHAPTER VIII 

RIGHT ILIAC PAIN 

Case No. 

1 24. Pericecal Tuberculosis 258 

125. Pericecal Tuberculosis 261 

1 26. Tuberculosis of the Cecal Region 261 

127. Normal Pregnancy 262 

1 28. Ovarian Cyst with Twisted Pedicle 263 

1 29. Tabes Mesenterica 264 

130. Ovarian Cyst with Twisted Pedicle 265 

1 3 1 . Ruptured Ovarian Cyst 266 

132. Ovarian Cyst 267 

133. Stone in the Right Ureter 268 

134. Tuberculosis of Right Tube 268 

Mm on- Colitis 269 

Appendix ular Colic (Chronic Appendicitis) 270 

137. Stone in Both Kidneys 272 



TABLE OF CONTENTS 9 

CHAPTER IX 

LEFT ILIAC PAIN 

Case No. Page 

S. Perforated Gastric Ulcer 277 

139. Bladder Cancer 278 

140. Constipation 280 

141. Syphilitic Adenitis 281 

142. Multilobular Ovarian Cyst (Twisted Pedicle) 282 

142.;. Diverticulitis 284 

General Consideration of the Diagnosis of Abdominal Pain 286 



CHAPTER X 

AXILLARY PAIN 

Case No. 

143. Pneumonia 288 

144. Broken Rib 292 

145. Unknown Infection 293 

146. Angina Pectoris 295 

147. Syphilitic Heart and Aorta 296 

148. Pneumothorax (Pulmonary Tuberculosis) 298 

149. Pleural Effusion 300 

150. Artificial Menopause 302 

151. Typhoid Fever 303 

152. Weak Heart; Acute Pulmonary Edema 305 

153. Gall-stones 307 

154. Sepsis with Thrombi 308 

155. Pus Kidney (Tuberculosis ?) 310 

156. Neurosis 312 

157. Pericarditis 313 

158. Thoracic Aneurysm 315 

159. Old Pleurisy 

160. Intercostal Neuralgia 319 

161. Costal Tuberculosis 320 

162. Starvation 320 



CHAPTER XI 

PAIN IN THE ARMS 
Case 

. Traumatic Neurosis 

. Aneurysm (Called Rheumatism) 327 

165. Mediastinal Neopla tati< 

Neuralgia 330 

i<>j. Infectious Cellulitis with Arthritis 

Tuber* ulosi of the Humerus 
[60. Septi< Osteomyi litii 

170. Cellulitis 

171. ( <r\i< a] Rib 

172. San oma Hum* rl 
Sarcoma Humeri 



IO TABLE OF CONTENTS 

Case No. Page 

i 74. Septic Osteomyelitis 340 

1 75. Thoracic Aneurysm 341 

176. Angina Pectoris (Syphilitic Aortitis ?) 343 

177. Metastatic Hypernephroma 344 

178. Malignant Lymphoma 346 



CHAPTER XII 

PAIN IN THE LEGS AND FEET 

Case No. 

179. Gonorrheal Arthritis 350 

180. Arteriosclerosis; Chronic Nephritis; Pleural Effusion; Terminal Infection. . 353 

181. Psoas Spasm Due to Nephrolithiasis 355 

182. Psoas Tear 357 

183. Pott's Disease with Psoas Abscess; General Tuberculosis 358 

184. Sciatica 359 

185. Neuritis with Herpes Zoster 360 

186. General Pyogenic Infection 363 

187. Gout 365 

188. Fractured Pelvis and Sepsis .« 366 

189. Acute Infection of the Hip .-. . . . 368 

190. Tabes Mesenterica; General Tuberculosis 369 

191. Flat-foot; Psychoneurosis 371 

192. Acute Foot-strain 372 

193. Alcoholic Neuritis 373 

194. Pneumococcus Arthritis, Endocarditis (?), and Pneumonia 375 

195. Gout 376 

196. Pelvic Neoplasm 380 

197. Carcinoma Uteri 381 

198. Sarcoma of the Femur 383 

199. Septic Knee 385 

200. Hysteria 385 

201 . Syphilis 386 

202. Gout and Gonorrhea 387 

203. Syphilis 389 

204. Cerebrospinal Syphilis (Vascular Crisis ?) 391 

205. Gonorrheal Arthritis 392 

206. Sepsis 394 

207. Flat-foot 395 

208. Sacro-iliac Strain 395 

209. Syphilitic Periostitis 397 

210. Syphilitic Periostitis 398 

211. Pneumonia 399 

212. Ischiorectal Abscess 400 



CHAPTER XIII 

FEVERS 

Shoki Fevers 405 

in nous I I a ers 405 



TABLE OF CONTENTS II 

Case No. Page 

213. Renal Infection (Bacillus Coli) 406 

214. Syphilis 407 

215. Pulmonary Tuberculosis 409 

216. Septic Thrombosis of the Lateral Sinus and Jugular Vein 410 

217. Perirectal Abscess; Perinephric Abscess 411 

218. Syphilis 413 

219. Interlobar Postpneumonic Empyema 415 

220. Poliomyelitis; Renal Infection 416 

221. Typhoid Fever with Relapse 418 

222. Typhoid Fever (Brief) 420 

223. Typhoid Fever (Afebrile when First Seen) 422 

224. Typhoid Fever; Impaction; Dysuria 423 

225. Pleurisy (Tuberculous) 424 

226. Pericecal Tuberculosis 426 

227. Phthisis 428 

228. Malignant Endocarditis 430 

229. Vascular Crisis 432 

230. Pneumonia and General Pneumococcus Infection 435 

231. Sepsis 437 

232. Pleural Effusion 439 

211. Epidemic Meningitis 441 

234. Unknown Infection 443 

235. Pneumonia 444 

236. Pneumococcus Infection 446 

237. Urticarial Fever 447 

238. Pharyngeal (and Transpharyngeal) Infection 449 

239. Streptococcus Sepsis 449 

240. Otitis Media 45 1 

241. Glandular Fever 452 

242. Catarrhal Jaundice 454 

243. Miliary Tuberculosis 454 

244. Estivo-autumnal Malaria 456 



CHAPTER XIV 
CHILLS 

Case No. 

245. Hepatic and Pulmonary Abscess 

246. Hysteria (with Arteriosclerosis ?) 4<>4 

247. Influenza 

248. Chronic Glomerulonephritis 

240. Oiiti> Media ^69 

250. Phthisis 470 

Phthisis 
252. Double Pleurisy Septi< ' 

Pneumonia 

\ i-< era! Syphilii 
255. Typhoid Fever 

Im biorei tal Ab o \&i 

257. Gall 

D p \\i!l.ir\ UMO . 



12 TABLE OF CONTENTS 

CHAPTER XV 

COMA 

Page 

Examination of Comatose or Convulsive Patients 486 

Certain Hoary Errors to be Avoided 486 

Causes of Coma and Convulsions 486 

Valuable Clues 490 

Case No. 

259. Stokes-Adams' Disease 492 

260. Mitral Disease (and Hysteria ?) 493 

261. Chronic Valvular Disease; Sudden Heart Failure from Unknown Cause. . 495 

262. Cerebral Tumor (?) 496 

CHAPTER XVI 

CONVULSIONS 
Case No. 

263. Alcoholism 501 

264. Hysteria 502 

265. Hysteria 503 

266. Epidemic Meningitis 508 

267. Chronic Interstitial Nephritis; Vascular Crisis 511 

268. Chronic Interstitial Nephritis; Uremia 513 

269. Otitis Media 514 

270. General Paralysis 516 

271. Stokes-Adams' Disease 518 

272. Stokes- Adams' Disease 520 

273. Tonsillitis and Congenital Heart Disease 522 

274. Cerebral Tumor 523 

275. Dementia Paralytica 525 

276. Lead-poisoning 527 

277. Syphilis 529 

CHAPTER XVII 

WEAKNESS 
Case No. 

278. Addison's Disease 535 

279. Alcoholism 538 

280. Secondary Anemia; Piles 539 

281 . Pernicious Anemia 540 

282. Apprehension 542 

283. Chlorosis 544 

284. Empyema (Tuberculous ?) 545 

285. Empyema 547 

286. Gastric Cancer 548 

287. Cancer of the Liver 550 

288. Diabetes Mellitus 551 

289. Diabetes Mellitus 553 

290. Lead-poisoning 554 

291. Myeloid Leukemia 555 



TABLE OF CONTENTS 1 3 

Case No. Page 

292. Alcoholic Neuritis 557 

293. Chronic Plastic Pleurisy 559 

294. Convalescence from Pneumonia 560 

295. Psychoneurosis 562 

296. Pus-tube 563 

2Q7. Staphylococcus Sepsis 565 

298. Phthisis 567 

299. Vertebral Tuberculosis 568 

300. Pernicious Anemia 570 

301. Graves' Disease 572 

302. Myxedema 573 

CHAPTER XVIII 

COUGH 

Varieties of Cough 576 

Case No. 

303. Pulmonary Abscess 579 

304. Aneurysm 582 

305. Bronchitis and Appendicitis 584 

306. Bronchitis and Asthma 585 

307. Streptococcus Bronchopneumonia 587 

308. Bronchiectasis . . : 588 

309. Bronchitis; Bronchopneumonia; Bronchiectasis; Emphysema 590 

310. Pneumonia 591 

311. Pneumonic Phthisis 593 

312. Traumatic Pneumonia 596 

313. Phthisis 599 

314. Miliary Tuberculosis and Diabetes 600 

315. Syphilitic Disease of the Lung 602 

316. Tuberculosis of the Lungs, Chronic Interstitial Nephritis, Hypertrophy 

and Dilatation of the Heart, Tubercular Ulcers of the Intestine, 

Hypernephroma 604 

317. Internal Urticaria 605 



CHAPTER XIX 

VOMITING 
Important Factors in the Production 01 Vomiting 611 

Case No. 

318. Alcoholism "11 

319. Appendii iti- f >i | 

320. Gastri< Cancer 6x4 

irii Cancer 616 

322. Cancer of the Sigmoid.. 6x8 

323. Chlorosii 

. ( 'on-i ipation : \< up i I 

325. ( 'on-lip. ition | \C11r. 

Catarrhal Jaundii e , 6a6 

327. Exhaustion 



14 TABLE OF CONTENTS 

Case No. Page 

328. Tabes with Gastric Crisis 630 

•.329. Traumatic Neurosis 63 1 

330. Gastric Neurosis 633 

331. Neurosis; Gastroptosis 635 

332. Gastric Ulcer; Pyloric Stenosis 637 

333. Tertian Malaria 639 

334. Malaria (Tertian) 642 

335. Tuberculous Meningitis 643 

336. Incomplete Miscarriage 645 

337. Chronic Interstitial Nephritis, Enteritis and Gastritis with Chronic 

Colitis and Terminal Streptococcus Septicemia 646 

338. Nervous Exhaustion 649 

339. Phthisis 650 

340. Pneumonia 65 2 

341. Vomiting of Pregnancy; Pleural Effusion 654 

342. Mitral Stenosis 656 

343. Cancer of the Ascending Colon 657 

344. Hysteria; Alcoholism; Drug Habits 659 

345. Chronic Intestinal Obstruction, Probably Due to Malignant Disease 661 

346. Neurosis; Morphin 662 

CHAPTER XX 

HEMATURIA 

Causes and Types of Hematuria 667 

Case No. 

347. Tuberculosis of the Kidney and Bladder 669 

348. Tuberculosis of the Bladder; Renal Tuberculosis (?) 670 

349. Renal Neoplasm 671 

350. Chronic Nephritis 673 

351. Cancer of the Bladder 674 

352. Cystitis of Unknown Origin 675 

353. Papillary Cystadenoma of the Kidney 677 

354. Hematuria, Cause Unknown 678 

355. Renal Irritation from Oxaluria 680 

356. Hypernephroma 681 

357. Gastric Ulcer; Hematuria, Cause Unknown 682 

358. Cystitis; Enuresis 683 

CHAPTER XXI 

DYSPNEA 

Causes of Dyspnea 689 

The Effect of Position and of the Time of Day 690 

Chkvm Sioki s' Breathing 690 

Case No. 

359. Hysteria; Polypnea 690 

360. Aortic Stenosis and Regurgitation 694 

361. Infertious Endocarditis, Myocarditis, and Pericarditis; Mitral Stenosis 

and Regurgitation 695 

362. Hyperplastic Endometritis; Debility 698 



TABLE OF CONTEXTS 1 5 

Case Xo. Page 

363. Bronchitis and Emphysema; Epilepsy 700 

364. Tuberculous Empyema and (Presumably) Phthisis 701 

365. Acute Cardiac Dilatation, Cause Unknown 704 

366. Acute Laryngitis 706 

367. Croup 708 

368. Chronic Glomerulonephritis 709 

369. Myocardial Insufficiency 710 

370. Mitral Stenosis and Regurgitation 711 

CHAPTER XXII 

JAUNDICE 

Types and Causes of Jaundice 715 

Associated Symptoms 716 

Intensity of Jaundice 719 

Case Xo. 

371. Catarrhal Jaundice 719 

372. Catarrhal Jaundice 721 

373. Tertian Malaria , 722 

374. Gall-stones 723 

375. Gall-stones 724 

376. Pancreatic Cancer 726 

377. Acute Yellow Atrophy of the Liver : 727 

CHAPTER XXIII 

NERVOUSNESS 
Case No. 

378. Diabetes Mellitus 731 

379. Phthisis 733 

380. Suppurative Nephritis 735 

381. Endothelioma of the Pleura; 'Acute Serofibrinous Pericarditis and General 

Arteriosclerosis 738 

382. Pernicious Anemia 739 

383. Chronic Interstitial Nephritis 741 



Appendices 743 

Index 747 



DIFFERENTIAL DIAGNOSIS 



INTRODUCTION 

J. THE PRESENTING SYMPTOM 

Cases of disease present, as we say, certain leading symptoms. 
They thrust forward, like a soldier who presents arms, a complaint such 
as pain, cough, or " nervousness," so that it occupies the foreground 
of the clinical picture. Such a "presenting symptom,'' 1 comparable to 
the "presenting part" in obstetrics, may turn out to be of minor im- 
portance when we have studied the whole case. But at the outset it 
has the power to lead us toward right or wrong conclusions in diagnosis, 
prognosis, and treatment, according as we have or have not learned 
the art of following it up. 

This book is an attempt to study medicine from the point of view 
of the presenting symptom. I hope to show how the complaints of the 
patient — fragmentary expressions of the underlying disease — should be 
used as leads, and how their lead can be followed to the actual seat of 
the disease. 

The plan thus outlined has three parts: 

(a) To present a list of the common causes of the symptoms 
most often complained of by patients, e. g., the causes of pain 
in the back, of vomiting, or of hematuria. 

(b) To classify these causes in the order of their frequency, 
so far as this is possible. 

(c) To illustrate them by case-histories in which the present- 
ing symptom is followed home until a diagnostic problem 
and its solution are presented. 

2. THE GROUPING OF REASONABLE POSSIBILITIES 

Diagnoses are missed— (a) Usually because physical signs are not 
recognized; {!>) occasionally because we do not think correctly. 

This book will not help any one to recognize the signs of disease, 
but it ought to aid physicians to Bolve those clinical puzzles wherein 
thedi missed because the patient's disease is not among those 

2 . i 



1 8 DIFFERENTIAL DIAGNOSIS 

considered and looked for. In other words, correct diagnosis depends 
upon what enters the doctor's head as possible, and on what his head 
does to sift the possibilities after they have entered it, as well as on the 
direct recognition of signs by physical examination. 

To throw open the mind's door and allow all disease to enter into 
consideration each time that we are called to a bedside is foolish in the 
attempt, and impossible in the performance. Each case should lead 
us to arrange before the mind's eye a selected group of reasonably prob- 
able causes for the symptoms complained of and for the signs discovered. 
What we select should depend upon the clues furnished us by the 
patient himself, or by the results of our own examination. 

When, for example, a patient pronounces the word "headache ," a 
group of causes should shoot into the field of attention like the figures on 
a cash register. Blue lips and finger-nails call up quite another group 
of ideas. Each clue or combination of clues should come to possess 
its own set of radiations or "leadings," determined partly by what we 
know of anatomy and physiology, partly by the hard knocks of clinical 
experience. 

3. ADVANTAGES OF THE PLAN HERE ADOPTED 

This way of working into a knowledge of medicine has the advantage 
of following the course of procedure by which we often question and 
examine patients in the office or in the clinic. We begin with the chief 
complaint and work inward and backward to the causes, the organic 
lesions, the evolution, probable outcome, and rational treatment of the 
case. Cases do not often come to us systematically arranged like the 
account of typhoid in a text-book of practice of medicine. They are 
generally presented to us from an angle, and with one symptom, often a 
misleading one, in the foreground. From this point of view we must 
reason and inquire our way back into the deeper processes and more 
obscure causes which guide our therapeutic endeavors. 

Why do so many practitioners treat symptoms only? Why are their 
diagnoses and the resulting treatment so full of vagueness, groping, 
hedging, and "shot-gun" prescriptions? 

Because they do not know how to get beyond symptoms. They 
have not been taught from the point of view of practice — i. e., of the 
presenting symptom. What are the possible causes and linkages of 
any symptom? Which of them are most probable? By what methods 
of questioning or of examination can the actual cause be found? This 
book aims to put into the physician's hand the means of answering these 
questions. 



INTRODUCTION 1 9 

I quite realize that the art of forming reasonable hypotheses about a 
case of disease and then of testing these hypotheses by such experiments 
as shall establish the correct and nullify the incorrect, is useless unless 
the methods of physical and chemical diagnosis have been mastered and 
unless the natural history of all common diseases has been learned bv 
observation and reading. But experience shows that a man may pos- 
sess a considerable acquaintance with physical diagnosis and with the 
course of disease, and yet be quite helpless in the presence of a suffering 
person, simply because he cannot apply his knowledge to this case. 
He can observe, he can remember, but he cannot constructively think 
and experiment. Every item of physical or chemical examination is an 
experiment made to test the soundness of an idea about the case in hand. 
Skill in thinking and in putting our thoughts to such a test of experiment 
are not learned either by drill in physical diagnosis or by reading upon 
the history of disease. 

To give such practice in thinking and working one's way into the 
mastery of a case of disease, through the intelligent verification of our 
thoughts by physical examination, is my object in the following chap- 
ters. They follow the method of case-teaching which I have used for 
eight years at the Harvard Medical School, applying there a method long 
employed at the Harvard Law School, and first described by Dr. W. 
B. Cannon. 

4. LIMITS 

To keep the book within reasonable limits I have selected 12 symp- 
toms (see Table of Contents) which are most often complained of by 
patients. I am well aware that others, such as diarrhea, constipation, 
loss of weight, paralysis, pallor, edema, purpura, or palpable tumors, 
might well have been discussed did space permit. 

5. VULNERABILITY OF ALL DIFFERENTIAL DIAGNOSIS 

The discussions which here follow each printed case art' concerned 
with differential diagnosis^ a very dangerous topic dangerous to the 
reputation of physicians for wisdom. It is, 1 suppose, owing to this 
danger that so little has been written on differential diagnosis and so 
much on diagnosis (non differential). To state the symptoms of typhoid 

perforation is not difficult. To give ;i Bet of rules whereby the condi 
which simulate typhoid perforation may be excluded i> exceeding]} 
difficult. Physicians art naturally reticent on such matters, slow 

to commit their thoughts to paper, and very suspicious of any attempt 

to tabulate their methods of r< 



20 DIFFERENTIAL DIAGNOSIS 

Yet all diagnosis must become differential before it can be of any use. 
All recognition of a lesion or a disease involves distinguishing possible 
sources of error and excluding them by a reasoning process — more or 
less definite and conscious. To be of any value, then, diagnosis must 
descend into the arena where it is questioned and assailed, where all 
sorts of errors and uncertainties arise to unsettle our wisdom. Those 
differential tables which we all distrust so much are really no more 
untrustworthy than the diagnoses we make in practice— for every diag- 
nosis expresses the results obtained by using such a table more or less 
unconsciously, as we exclude possible errors and alternative diagnoses. 

I am very well aware, therefore, that the differential diagnostic state- 
ments which fill this book are one and all subject to such limiting phrases 
as "in most cases," "as a rule," etc. This must always be so as long as 
the list of possible causes or diagnoses which we call to mind when we 
attack any diagnostic problem is an incomplete list (or possibly an over- 
inclusive one) . To decide which of the known causes of jaundice is the 
cause of the yellowness of Miss Smith we investigate, by the experiments 
known as "history," "physical examination," and "therapeutic test," 
a list of these known causes. But some day we may meet a case in which 
none of these well-known causes is present. Some new cause, so far 
unlisted, may, in fact, be at work. There are probably as many fish in 
the sea as ever came out of it; the unrecognized infections, poisons, 
and maladjustments are probably as many as those already described in 
text-books. 

All this unconquered territory lies about us, full of hidden dangers to 
our differential diagnosis — i. e., to all practical diagnosis. 

One other limitation must be mentioned. Whenever one says: 
"The symptoms produced by typhoid (or by peritonitis or by renal 
stone) are such and such," one should tacitly add — "provided that it 
produces any characteristic symptoms at all." It is certain that the 
three diseases just mentioned may exist without producing any symp- 
toms of which the patient is aware. It is probable that this is true of 
all other diseases. But as we can have no direct dealing with these 
silent types of disease, we can give them place in the theater of our 
reasonings only in that outer circle reserved for "possible sources of 
error," a great and distinguished company whose presence serves to keep 
us within the bounds of humility and of scientific caution. 

Meantime we must go on with our work of finding the most prob- 
able among the known causes and discoverable types of disease. 



INTRODUCTION . 21 

6. OMISSIONS 

Some diseases are omitted by choice, others by necessity. The 385 
cases which I have selected for study were all seen in private or hospital 
practice. To prevent the possibility of their recognition by the individ- 
uals concerned I have changed or omitted certain personal details. 
In essentials the cases are reproduced as they were observed. 

I have chosen no cases in which diagnosis was obvious and none in 
which it was impossible or dependent chiefly on good luck. To avoid 
the obvious, I have omitted discussion of such clinical pictures as the 
following: 

Patient of twenty-five, who has had two attacks of rheumatic fever, complains of 
dyspnea, dropsy, and cough. Examination shows a rapid, irregular, transversely enlarged 
heart, with a presystolic murmur and thrill at the apex and an. accentuated pulmonic 
second sound. There is evidence of passive congestion of the lungs, liver, legs, and gas- 
tro-intestinal tract, with dropsy of the serous cavities. 

There may be many difficulties in physical examination here, but 
none in the reasoning processes which lead us to the examination and 
thence to our conclusions. Obvious maladies, such as pharyngitis, 
peripheral gangrene, or talipes, have been omitted for the same reason; 
likewise all those in which diagnosis is made only by incision; e. g., acute 
pancreatitis, certain breast tumors. 

AYhile selecting cases in which diagnosis was difficult, but not impos- 
sible, I have tried to choose those in which in the end we could attain a 
reasonable certainty. Absolute certainty is attainable only as the result 
of operation or autopsy, and not always then. Hence it is possible that 
certain of my readers may disagree with the diagnosis finally reached in 
some cases. This is inevitable in a book of this kind, as it is in actual 
practice. Book and practice alike can only reflect the existing state of 
medical knowledge, medical uncertainty, and ignorance. But I sin- 
cerely hope that my errors may be pointed out by correspondents. 

After restricting the field in the way just mentioned, J have tried 
to exemplify in each chapter all the diseases which often lead a patient 
to consult his physician, complaining of the symptom which forms the 
subject of that chapter. Now and then, however, 1 have altogether 
omitted some importanl disease because 1 could not find any suitable 
example of it within my own cases or among those which I had myself 

studied. 

\n a few cases certain items have been omitted here because they 
were likewise omitted in the version of th< en me by the attending 

physician. My t;i '<> notice their conspicuous or inconspicuous 



22 DIFFERENTIAL DIAGNOSIS 

absence, and to act accordingly. It seems justifiable, therefore, to impose 
a similar task upon my readers. 

7. EXPLANATION OF DIAGRAMS AND CHARTS 
The book contains figures, tables, diagrams, and charts. The two 
last need some explanation. 

The diagrams, which are introduced in each chapter just before the 
illustrative cases, represent an attempt (the first that I know of) to esti- 
mate the relative frequency of the commoner causes for each symptom 
discussed. This estimate, which can be but approximate, rests upon the 
following data: 

(a) An enumeration of the total number of cases of every disease 
treated at the Massachusetts General Hospital during the last six years. 
About 180,000 cases are thus classified according to diagnosis, and the 
relative frequency of each disease in this material is thus roughly com- 
puted. But these figures do not give us the relative frequency of any of 
the symptoms (such as jaundice or headache) studied in this book. 
Many cases of gall-stones are not jaundiced; hence we cannot directly 
compare the number of gall-stone cases with the number of cirrhoses 
(for example), but must estimate the percentage of jaundiced cirrhoses 
and jaundiced gall-stone disease in each group. This is done by con- 
sulting — - 

(b) Statistical articles from the literature in which the percentage 
occurrence of each symptom in a large series of cases is worked out. 
Such statistical articles, however, are not common. In Rolleston's 
magnificent monograph on the liver almost every statement has a 
statistical basis, and the wearisome recurrence of phrases like "as a 
rule," "not infrequently," "sometimes," etc., is replaced by concrete 
quantitative estimates. But there are not many such books. Hence 
I have been forced in some instances to compute the percentage occur- 
rence of a symptom by — 

(c) The study of the symptom and of the frequency of its occur- 
rence in 250 cases of the disease in question; these cases were taken 
trom the more recent records of the Massachusetts General Hospital. 

By the methods described under (a), (b), and (c) the length of every 
line in every diagram has been calculated. I am well aware that there are 
numerous sources of error in these calculations. The diagnoses in the 
Massachusetts General Hospital records may be faulty in some instances, 
though the large number of cases used tends to minimize such errors. 
The statistical articles referred to under (b) may be incorrect, and do not 
often include a very large bulk of cases. Finally, the number of cases 



INTRODUCTION 23 

referred to in the calculations under (c) is smaller than I should wish. 
More important than any of these errors are the absolute omissions which 
are sure to be discovered among my tables of causes. I hope for much 
aid from my critics in supplying such missing links. Indeed, I am con- 
fident that some one will be so indignant at my mistakes that he will at 
once begin to write a better book on similar lines — a result which I most 
earnestly desire. 

The sources of my information regarding the figures used in the dia- 
grams are given in Appendix A, p. 743. 

The list of causes represented in these gridiron-shaped diagrams is 
not wholly the same as that exemplified in the illustrative cases. Only 
the commonest, clearest, and most important causes are drawn in upon 
the "gridirons." Still a third group of causes, which do not lend them- 
selves either to diagrammatic or to detailed illustrative treatment, are 
mentioned briefly in the introductory section of each chapter. Hence 
the complete list of causes discussed is to be found — (a) In part in the 
gridirons; (b) in part in the illustrative cases; (c) in part in the intro- 
ductory section of each chapter. 

The Charts. — Beside the three lines, which represent in the ordinary 
way the course of temperature, pulse, and respiration, there is a fourth 
line interwoven with the respiratory curve, and distinguished by the 
presence of cross striae, like the railroads on a map. This line stands for 
the twenty-four-hour amount of urine measured in ounces. 

In the charts the line of this type - n mnnm . nn n "" 

indicates the amount of urine in ounces, while the line cut by stars, as 
follows, * * * represents the blood-pressure. 



CHAPTER I 

PAIN 

GENERAL CONSIDERATIONS 



Before we begin to study the cause or the cure of any pain, we need 
to convince ourselves that it really exists. Not only in the cases of 
deliberate deception or malingering, but in dealing with perfectly honest 
people, we are liable to error. Many persons, especially of the less 
educated classes, do not distinguish between pain and the other varieties 
of discomfort, such as itching or a sense of pressure. Many patients who 
say at first that they have a headache or a stomachache may be brought, 
by a little questioning, to recognize that they are referring to a sense of 
weight, constriction, or vague discomfort, rather than to pain in the 
narrower sense. 

As evidences of pain we are accustomed to scrutinize: 

(a) The facial expression and bodily movements. 

(b) The account of some onlooker, such as a nurse or relative. 

(c) The results, such as emaciation or muscular weakness, often 
produced by long-continued suffering. 

(d) The blood-pressure. 

When a patient's face is contorted and his body writhes, stiffens, or 
doubles up, we can have no doubt that he is suffering, unless we believe 
him an impostor, but obviously these evidences of pain may be easily 
simulated or exaggerated. 

It is in such cases that we need the testimony of some third person 
who can watch the patient at a time when he supposes himself to be alone. 
Many patients who do not intend to deceive us show far greater evidences 
of suffering when a doctor, a nurse, or a friend is near at hand than when 
they believe they are unobserved. This is partly due to the fact that a 
perfectly genuine though distinctly mild lesion is very much more pain- 
ful to the patient when his self-pity is aroused by the presence of a sym- 
pathetic onlooker. 

When a patient who bears the ordinary marks of blooming health 
states that he has been suffering excruciating pain for many months, 
the Jack of any of the ordinary evidences of suffering naturally and 

24 



PAIN 25 

properly make us take his statement with a grain of salt. Chronic 
suffering is pretty sure to leave its mark on the face and body. 

In cases of suspected malingering, when an individual states that a 
certain motion or a certain pressure upon a supposedly tender point 
causes great suffering, we may control his statement to a certain extent 
by measuring the peripheral blood-pressure at the time. Severe pain 
almost always causes a notable rise in blood-pressure, and if we find noth- 
ing of the kind, we may rightly conclude that if pain is present, it is 
probably not intense. 

DEGREE OF PAIN 

I have long been accustomed to compare, as a matter of routine and 
in every case, the extent and quickness of the knee-jerks with the patient's 
statement regarding his own suffering. I have found that those who 
describe all their troubles as "terrible," "awful," "fearful," and the 
like, are very apt to have lively knee-jerks, and that those who are more 
moderate in their expressions have usually less active reflexes. It 
seems quite probable that there is a parallelism here between reflex 
sensibility and sensitiveness to pain. Those who respond to a given 
stimulus by an exaggerated knee-jerk might well be expected to respond 
to a given cause of pain by an exaggerated complaint. So it has seemed 
to me as a result of many observations, and I have come to believe that 
people are more likely to be oversensitive and to exaggerate their suffer- 
ings when the knee-jerks are unusually lively. 

This is, of course, a very rough and uncertain method of measuring 
pain, and would perhaps be more truly described as an attempt to meas- 
ure the severity of the cause of pain, rather than of the pain itself. We 
are greatly in need of some more accurate method of estimating how 
much people suffer. For the present, we have to judge largely by such 
uncertain evidences as were mentioned in the last section— facial expres- 
sion, bodily movement, the accounts of onlookers, and the evidences of 
such physical changes as pain might produce. In addition to these 
we get a certain amount of information by asking: 

"Does the pain prevent you from working?" 

"Does it prevent sleep?'' 

"Does it take away appetite, the rapacity for movement and en- 
joyment in the ordinary function- of life?" 

We know that certain races- for example, the Chinese— are much 

less sensitive than others to pain in that they exhibit far less evidence OJ 
"shock" after a bullet wound or a di>eml>o\velmcnt. We can only Lmcss 

at the sensory side of this phenomenon, but the absence of the ordinary 

organic effei tS produ< ed by the same injury in a Caucasian gives us some 



26 DIFFERENTIAL DIAGNOSIS 

ground for believing that the suffering is proportionately small. In all 
probability there are similar differences between individuals of the 
same race. 

Though women are generally believed to be more highly organized 
and more sensitive than men, it is a well-known fact that they bear pain, 
especially prolonged pain, better than men. I have never heard any 
plausible explanation of this fact. 

TYPES OF PAIN 

Most of the adjectives which are attached to the complaints of pa- 
tients, either by themselves or in the text-book description, give us no in- 
formation of value because they are not regularly associated with any 
one disease. Boring pains, tearing pains, and knife-like pains do not 
characterize any particular disease. Nevertheless, there are a few dis- 
tinctions of importance. 

Pains that recur rhythmically, or at regular intervals, working up 
gradually to a climax each time, and then disappearing suddenly or 
gradually, are often associated with hyperperistalsis within some, hollow 
tube, such as the intestine, the ureter, the bile-ducts, or the uterus. To 
such pains the name of "colic" is traditionally attached, though it is 
often used much more vaguely to denote any type of severe and sudden 
pain in the abdomen. 

Throbbing pains,- increased momentarily with each beat of the heart, 
are characteristic of vascular hyperemia, such as occurs about the roots 
of an inflamed tooth. In connection with vasomotor headaches and in 
dysmenorrhea we occasionally see the same phenomenon. 

Pain with a sense of constriction is of great diagnostic value when it 
occurs in the precordial region, pointing, as it does, in the great majority 
of cases, to angina pectoris as its cause. Other diseases producing pain 
in this region are rarely, if ever, accompanied by this sense of constriction, 
which the patients often express in very vivid phrases, e. g., "as if I were 
squeezed in a vise," or "as if some one gripped my heart in his hand." 

Thoracic or abdominal pain increased or produced by exertion and 
promptly relieved by rest is almost always due to the cause just men- 
tioned — angina. Many pains supposed by the patient to be due to in- 
digestion, to rheumatism, or to neuralgia may thus be recognized as 
anginoid. 

Pain that shoots and darts, especially if it follows the course of some 
nerve-trunk, usually turns out to be neuralgic. Tn many cases such a 
pain is associated with prickling, burning, numbness, or other pares- 
thesias. 



c 



PAIN 27 

RELATION OF PAIN TO OTHER FACTS 

A careful history of the bearing of various factors in the patient's 
habits and environments upon the occurrence or the severity of pain is of 
prime importance in diagnosis. Among the elements to be taken account 
of are the relation of pain to: 

(a) The time of day. 

(b) The position of the body. 

(c) The taking of food. 

(d) The effect of motion involving the painful part, or of jolt- 
ing of the entire body. 

(e) The effect of emotional excitement. 

(f) The effect of occupation. 

(g) The effect of season and the weather. 

(//) The mode of relief — e. g., by heat, cold, food, vomiting, 
medicine, rest, occupation. 

Neurasthenic headaches and the pains of chronic joint troubles are 
apt to be worse in the morning and to improve as the day goes on. Any 
pain associated with fever and infection is likely to be worse in the even- 
ing, when the temperature is at its highest. 

Pains affected by position are especially those due to diseases of the 
joints and muscles, such as lumbago, sacro-iliac strain, all the types of 
arthritis, stiff neck, and the like. Almost all varieties of pelvic disease 
are worse when the patient is on her feet, as the position is likely to 
involve some pressure or dragging upon painful points. For the same 
reason the surgical affections of the kidney and all diseases which in- 
volve splenic enlargement are usually more painful when the upright 
position is assumed. Occasionally a headache is distinctly unproved or 
aL r L r navated when the patient lies down. The distress accompanying 
uncompensated cardiac disease is always aggravated by recumbency. 

Most muscular pains arc aggravated by the use of the muscle; hence 
the presence of such an aggravation may help us to distinguish muscular 
pains from those of different origin. Jt must be remembered, however, 
that in some cases the pains of neuritis arc increased by use of the part, 
even when no muscular lesion i> discoverable. The motion of coughing 
brings great distros in pleurisy, pneumonia, and all diseases involving 
the intercostal m Anginoid pains an- increased not only by 

motion, but by any other cause which raises blood pit a&tric 

jtion, mental exertion, or e xci tement). 

( m the other hand, some pains are made worsr by rest ; for example, 
all types of habit pain-, to which 1 shall refer more in detail in the ne\l 

m-< tion. The pains of ( hronic joint troubles are worse immediately after 

. when the patient attempts to DHOVC his Stiffened joints. 



28 DIFFERENTIAL DIAGNOSIS 

The effect of jolting, as in riding on a rough road or a rough-gaited 
horse, is traditionally associated with an increase of the distress pro- 
duced by stone in any part of the urinary tract. Doubtless this is a true 
observation, but there are many exceptions to the rule. 

Aggravation of any pain by the taking of food properly inclines us 
to believe that the pain is produced in the stomach (gastritis, gastric 
ulcer, gastric cancer, gastric neurosis). Many intestinal pains, however, 
are likewise produced or increased when food enters the stomach. 
Thus the sufferings due to enteritis and to chronic intestinal obstruc- 
tion are often much worse immediately after a meal. It appears to 
be true, moreover, that pain due to gall-stones, and even to chronic 
appendicitis, may be set agoing by the presence of food in the 
stomach. I have already referred to the excitement of anginoid pain 
through the rise of blood-pressure produced by the act of digestion. 
Possibly an accompanying gaseous distention may help to call out the 
attack. 

Relief of pain by food is characteristic of peptic ulcer and of hyper- 
chlorhydria, as well as of the vaguer gnawings due to hunger. 

Many types of muscular, articular, and neural pains are subject 
to aggravation as the result of various meteoric conditions, of which we 
understand all too little. It cannot be questioned, I think, that the 
muscular pains involved in lumbago and stiff neck are more apt to be 
present in damp, rainy weather, such as occurs in the spring and fall, 
than in dry heat or dry cold. The persons who can foretell a storm by 
the disagreeable sensations in the neighborhood of diseased joints are 
very numerous, but I have never been able to associate this form of 
prophecy with any one type of disease. I am also convinced that the 
approach of a thunder-storm may precipitate a headache not only in 
those predisposed to migraine, but in other sensitive persons. Whether 
this is due to barometric, to electric, or to quite unknown conditions 
I am unable to say. Many of my patients have noticed that their 
headaches are more apt to occur on especially bright, bracing days, 
when the air is unusually clear. 

Relief by vomiting does not prove that the disease is of gastric origin. 
Intestinal pain, biliary colic, renal colic, and the sufferings of duodenal 
l ulcer may also be relieved by emesis. 

Relief by heat or by cold cannot be predicted for any variety of 
pains. The same disease in different individuals may be assuaged now 
by the one now by the other agencies. It is wholly a matter of experi- 
mentation. But in my experience most of the pains which cold relieves 
are more completely and more permanently abated by heat. 



PAIN 



2 9 



HABIT PAINS 
The term is a misleading one, and needs more explanation than the 
fact. The genesis of the latter may be described as follows: 

(a) Some exciting, terrifying, or mortifying event draws the patient's 
attention to a certain part of his body — the cardiac region or the pharynx, 
for example. Then — 

(b) As the microscope discovers bodies invisible to the unaided eye, 
so the patient's focused and concentrated attention discovers sensa- 
tions due probably to some of the physiologic changes occurring normally 
in the part to which attention has, unfortunately, been directed. These 
changes go on normally without producing any sensation noted by the 
brain. But when the brain is sensitized, especially in relation to the part 
attended to, even the heart-beat may be felt as painful, or the normal 
blood, lymph, and nerve-currents of the pharynx may be magnified 
into painful events. 

(c) The "set" of attention produced by habit keeps the brain "on 
edge," keyed up to perceive the slightest glimmer of sensation, such as 
we ordinarily disregard. 

(d) Finally, some actual disturbance of the function of the part 
may follow this abnormal interference of consciousness in activities 
which should be subconscious. The heart-beat becomes irregular; 
the pharynx secretes abnormally. This redoubles, of course, the 
patient's alarmed concentration upon the part, and so a vicious circle 
is established. 

Such a circle is broken, and the diagnosis of habit pain confirmed 
when we succeed in switching off the patient's attention upon other 
subjects — and thus making him forget, at any rate for a time, his habitual 
sufferings. 

THEORIES REGARDING THE PRODUCTION OF PAIN 
I wish to refer briefly to the beliefs of McKenzie and Head, also to 
those of J. Pal, regarding the means whereby pain is produced under 
certain conditions. 

To James McKenzie 1 and to Henry Head 2 we owe the elaboration 

of a theory whereby pain and cutaneous hyperesthesia are viewed as 

iated manifestatioiiyof morbid irritability in one or another group 

of spinal ganglion cells. According to their theory, this irritability 

is due to impulses transmitted from a diseased Organ, which, though 

not itself the seal of pain, yet causes in the corresponding spinal segment 

1 James McKenzie, Symptoms Slid their Interpretatioi 

1 Henry Hi .1 d, I >n 1 >1 turl 11 1. *\i, p. 1; si 

mbaequent numl 



30 DIFFERENTIAL DIAGNOSIS 

a disturbance which is transferred thence to the periphery of the body, 
and there recognized by the individual as pain in a place often far distant 
from the organ diseased. 

Thus these writers account for the umbilical pain experienced in 
intestinal obstruction, no matter where the stoppage occurs, by supposing 
that all parts of the intestine are represented in the cord by the same 
spinal segment, and that the umbilical region is the seat of centrifugal 
impulses from that center, resulting in cutaneous hyperesthesia, as well 
as pain. 

The best confirmation and exemplification of this theory are seen in 
the so-called radiations of the pain known as angina pectoris, and in the 
similar radiations from the site of biliary colic. It is difficult to account 
for the arm pains of angina and the shoulder pains of gall-stone disease 
on any other hypothesis, and if all other types of pain could be traced 
with similar accuracy to a spinal segment, rather than to an organ 
directly underlying the painful spot, the theory of McKenzie and Head 
would deserve our unqualified assent. In point of fact, however, the 
two examples given above are almost the only ones in which the theory 
is clearly verifiable. The pain of appendicitis, of pleurisy, most kid- 
ney pains and splenic pains do not well accord with the tneory, and 
the zones of cutaneous hyperesthesia which are essential to the con- 
firmation of their theory have seldom been found by other observers. 
In spite of my profound respect for the originators of this theory, I have 
been unable to apply it successfully in clinical work, except in the two 
diseases just referred to, and in the localization of spinal lesions. 

More useful, on the whole, is the book on Gefasskrisen, 1 in which 
Pal elaborates, upon the basis of careful observation, both at the bed- 
side and at the dead-house, a theory of the origin, not of all pains, but of 
certain paroxysmal types of suffering associated especially with the vessels 
of the brain, the heart, and the kidney, but to a lesser extent with those 
of the intestine and of the extremities. He supposes that arterial spasm 
(favored and prepared for by arteriosclerosis, by uremia, by lead-poison- 
ing, and by the nerve lesions of tabes) is the cause of a large group of 
pains, paralyses, and other functional disturbances which had never before 
been brought together under any single explanation. Taking lead-poison- 
ing as an impressive example of the theory, he points out that we have 
here a notable rise of blood-pressure, associated sometimes with cerebral 
crises (headache, convulsions, coma), often with abdominal crises 
(lead colic), and occasionally with anginoid seizures. In arteriosclerosis 
we have likewise cerebral, abdominal, and cardiac crises, and, in addi- 

1 J. Pal, Gefasskrisen, Leipzig, 1905. 



PAIN 



31 



tion to these, well-marked peripheral crises (intermittent claudication). 
In uremic and eclamptic poisoning we have likewise cerebral and ab- 
dominal crises. In tabes dorsalis the abdominal crises are the most 
familiar. 

In all these affections postmortem examination may demonstrate 
that there is no gross lesion, such as cerebral hemorrhage or throm- 
bosis, coronary occlusion, or blocking of a peripheral artery. Indeed, 
the arteries and the surrounding tissues may appear almost or quite 
normal postmortem. It is natural, therefore, to assume some functional 
change, such as spasm, to account for the pain, paralysis, and other 
functional changes recognized at the bedside. In favor of the hypothe- 
sis of vascular spasm, or Gefasskrisc, are two considerations: 

(a) A rise of blood-pressure has many times been demonstrated by 
Pal before, as well as during, the crisis. This hypertension cannot 
be accounted for as a result of pain, since in many of Pal's cases it pre- 
ceded the pain. He has found it in the gastric crises of tabes, as well as 
in the uremic, saturnine, and arteriosclerotic cases. 

(b) During an attack of transient blindness occurring in a patient 
who had been subject to various other " crises," ophthalmoscopic ex- 
aminations showed a high-grade spasm or contraction of the retinal 
arteries. 

So much for the theory and the evidence on which it is based. It 
seems to me a good working hypothesis as an explanation of many 
of the transient amauroses, aphasias, monoplegias, hemiplegias, and 
headaches associated with chronic nephritis. Like other theories, 
it is to be tested partly by what it enables us to discover. Like the 
atomic theory, it may lead us to perceive and so to fill in certain gaps, 
such as appear in the following table: 

CRISES 



1. Artcrios* lerosis 

2. Nephritic hyperten- 
sion ("uremia'') 

3. Tabes dorsalis 

4. Plumhism 



Cerebral. 


Canli.t' . 


in.il. 


Peripheral. 


Pulmonary. 


+ 


+ 


+ 


+ 


+ ? 


+ 


+ 


+ ? 


— 


+ ? 


— 


- 


+ 


+ 


- 


+ 


+ ? 


+ 


- 


- 






I may here acknowledge my deep indebtedness to Rudolf Schmidt's 
on Pain, 1 which has guided and confirmed my own ot» 

dons on many points. 

1 Pain ' ' n and I H Rudolf & hmi.it ; tran 

, B. Iippii my, 1908. 



CHAPTER II 
HEADACHE 

U GENERAL CONSIDERATIONS 

In discussing this, probably the commonest of all symptoms, I shall 
exemplify by cases only such causes as are likely — (a) to be complainec 
of by the patient as his leading symptom, and (b) to occasion diagnosti- 
difficulties. Others will be briefly mentioned here. 

i. Anemia of any type — pernicious, chlorotic, posthemorrhagic — 
is now and then accompanied by headache, usually as a minor symptom. 
It is noteworthy, however, that intense anemia often persists for months 
without producing any headache whatever. It may well be doubted 
whether anemia is ever in itself the cause of headache. 1 

2. Fatigue y hunger, and bad air often produce a headache (perhaps 
due to the circulation of "fatigue poisons") whose cause is made obvious 
by its disappearance after rest, food, and fresh air. 

3. Poisons, such as alcohol, morphin, and lead. Except after a 
drinking bout, I have never known a patient whose chief complaint, as a 
result of any of these poisons, was headache. Other symptoms usually 
occupy the foreground. 

4. Arteriosclerosis. — It has long been stated in medical lectures and 
text-books that the headaches of elderly persons are frequently caused by 
arteriosclerosis. My own experience, however, coincides entirely with 
that of Thomas, of Walton, and of Paul, 2 who deny any such asso- 
ciation. In my experience, it is only when the kidney is extensively 
involved and blood-pressure thereby raised that headache results from 
arteriosclerosis. 

5. Indigestion and Constipation. — Gastric stasis, arrested digestion, 
and the resulting abnormal fermentation of food often lead to a head- 
ache which needs no further mention here. The patient can usually 
make the diagnosis for himself. The same is often true of the headaches 

1 Of 697 cases of pernicious anemia studied by me, 300 had no headache at any time. 
See Osier's Modern Medicine, vol. iv, p. 622. 

2 Walton and Paul, Jour. Amer. Med. Assoc, 1908; Thomas, Osier's Modern Medicine, 
•nh vii, p. 336. 



Causes of Headache 



1. FATIGUE, BAD AIR, AND HUNGER 

2. CONSTIPATION AND INDIGESTION ("BILIOUS- 

NES 

3. ALCOHOL (THE "DAY AFTER" HEADACHE' 

4. EYE-STRAIN AND INTRINSIC DISEASES OF 

THE EYE 

5. INFECTIOUS DISEASES (ONSET) 

6. MENSTRUATION 



CASES TOO MANY AND TOO 
VAGUELY ENUMERABLE FOR 
GRAPHIC REPRESENTATION. 



7. PSYCHONEUROSES 

8. NEPHRITIS 

9. MENINGITIS 

10. SINUSITIS 

11. TRIGEMINAL ) 

NEURALGIA I 

12. "INDURATIVE" 

13. MIGRAINE 

14. BRAIN TUMOR 

15. SYPHILITIC ) 

PERIOSTITIS 1 I 

16. UNKNOWN CAUSE 



1039 
602 
172 
157 

117 

89 
89 
46 

16 

619 



1 The diagnosis <<f intracranial syphilifl seem to me still to uncertain that I have 

not included it hi re. 



HEADACHE 35 

resulting from constipation, miscalled "lithemia," "biliousness," or 
"torpid liver." 

A remarkable feature of this type of headache is its swift disappear- 
ance, in certain cases, after defecation. From several very intelligent 
patients I have heard repeatedly the story of a headache that disap- 
peared, wholly or mostly, within a few minutes of the time of defeca- 
tion. This is hard to reconcile with any chemical theory regarding the 
origin of such a pain. 

6. Many common infections — rhinitis, tonsillitis, the exanthemata, 
etc. — are often accompanied by headache, which, however, is rarely 
the patient's chief complaint. There are other infections — examples of 
which will be given below — which cause so severe and persistent a head- 
ache that it becomes the "presenting symptom." 

7. The headache sometimes accompanying otitis media and other 
forms of aural disease gets its recognition, in the vast majority of cases, 
from the concurrent aural symptoms. 

8. Menstruation is often preceded or followed, less often accompanied, 
by headache the exact origin of which is very obscure. 

9. Trigeminal neuralgia, with or without the paroxysms and spasms 
of tic douloureux, presents, as a rule, no serious difficulties in diagnosis, 
and will, therefore, not be further mentioned here. Mild types may 
originate in dental caries or other peripheral irritations. The severer 
forms appear to be due to changes in the Gasserian ganglion. 

10. Insolation, with or without actual sunstroke, has often been 
listed among the causes of headache. In my experience, however, there 
is usually a large neurasthenic element in these cases, and the history 
of insolation is often vague and forced. 

11. Adolescence is frequently associated with a headache for which no 
local cause can be found. We connect such headaches vaguely with 
adolescence, because they pass off with the end of that period. 

12. Cerebral concussion — as in a foot-ball game — is a common cause 
of headache, which usually presents no diagnostic difficulties. 

13. Indurative Headache. — u This— probably the most frequent 
form of headache- seems to be unknown to the majority of physicianSi 
although it has been described in U \t books for decades" (Edinger, in 

! Deutsche Klii 
The term "indurati an attempt to characterize the 

malady without committing ourselves to any theory regarding it- i 
or morbid anatomy. In some of the older books it is referred to as 

* Translated under title of Modern Clinical Medicine, in \\\<- volume on I 1 f 



36 



DIFFERENTIAL DIAGNOSIS 



"rheumatic headache." Its distinguishing feature is the presence 
of painful "indurations" near the insertions of the muscles at the 
occiput. Bits of the trapezii, sternocleidomastoids, scaleni, or splenii 
become sensitive, uneven, and nodular, " as if something were deposited 
in the substance of the muscle." (See Fig. i.) 

Pain which is chiefly, but not exclusively, occipital is associated with 
these "indurations," and disappears when they are removed by mas- 
sage. It is on this account that the disease is so much better known tc 




Fig. i. — The points upon which indurations are most frequently found (Edinger). 

the masseurs and to the physicians who have studied and practised 
massage than to the medical profession at large. Writers on massage 
do not hesitate to speak of the "indurations" as foci of "chronic myo- 
sitis" but there are, so far as I know, no histologic examinations on 
which we can base such a term. Edinger l apparently considers the con- 
dition a neuralgia. Swelling of the neighboring lymph-glands and of 
the cervical sympathetic ganglia is mentioned by some writers. 

The sensitiveness to touch extends to the aponeuroses over the skull, 

1 P. 865 in the volume above cited. 



HEADACHE 



37 



to the vertex and even to the frontal region; also down along the outline 
of the trapezius on the shoulder. In this as in many other respects it 
resembles "lumbago" and "stiff neck." 

The disease is often referred to as "rheumatic," because it seems in 
some cases to follow exposure to cold and wet, e. g.: "A few days before 
the appearance of the symptoms he had been overtaken by a hailstorm 
while riding a bicycle." To some these statements still carry convic- 
tion, c. g. } to Edinger, who says: "It is certain that refrigeration may 
produce the disease." 

I have, I regret to say, no cases in my own experience which exem- 
plify this disease. I have referred to it here because it seems to me to 
deserve more careful study by clinicians and because of Edinger's 
statement, based on his extensive experience at the Neurological Institute 
in Frankfurt-am-Main, that it is probably the most frequent form of 
headache, and that: "The examination of the insertions of the muscles 
should never be neglected in any case of headache." 

14. Vasomotor Headaches. — Though vasomotor disturbances may 
occur in various types of headache, especially in migraine, there remains 
a group of cases in which only the vasomotor trouble (vasoparalysis 
and vasodilatation) is discoverable as cause. These patients have very 
red faces in the attack, and usually show reddish blotches or striae over 
the rest of the body. The diagnosis is made by the presence of the above 
signs and by exclusion of all other known causes. 

2. POSITION AND NATURE OF THE HEADACHE 

(1) Many text-books map out the surface of the skull with special 
"headache areas," reminding one of a phrenologic map, but in my 
experience there is not often much to be learned from the position of a 
headache. Ocular headaches often begin or center near the eyes; pains 
due to otitis media often spread from an initial focus near the ear. 
Inflammations of the antrum or frontal sinus cause pain over the a Ike ted 
cavity. The pain of syphilitic periostitis corresponds with the position 
of the lesion. Migraine, with its unilateral distribution, and trigeminal 
neuralgia have also a typical distribution. 

On the other hand, ocular and aural headache is often not thus 
localized, and the pain due to any of the other familiar causes anemia, 
infection, brain tumor, constipation, menstruation, neurasthenia) may 
be in any part of the head, and is often unilateral, bo as to be mistakes 
for migraine. 

(2) The kind of pain is 1 <f very little significance: throbbing, 
dull, burning, boring headaches me encountered in all sorts of di* 



38 DIFFERENTIAL DIAGNOSIS 

A sense of constriction and pressure is mentioned by many patients of 
the psychoneurotic group, especially if they have been to France and 
have been told that they have a "tete en casque." 

(3) The severity of headache is probably greatest in organic diseases 
of the brain or periosteum (cerebral tumor, meningitis, syphilitic perios- 
titis), in the paroxysms of tic douloureux, and in those of migraine. 

(4) Chronic Jieadaches, sometimes lifelong, are associated with all 
the psychoneuroses (neurasthenia, hysteria, psychasthenia) , and are 
sometimes present without any discoverable cause. They are often 
referred to the "base of the brain" (meaning the nape of the neck). 
Blows on the head, sunstroke, arsenical poisoning, and all sorts of 
"reflex" disturbances (pelvic, ocular, gastro-intestinal) are often vainly 
invoked as causes, and the term "constitutional" is often attached to 
such pains, but a frank confession of our ignorance seems to me 
better. 

(5) The time of day markedly influences some headaches; those 
associated with frontal sinus disease often begin at the same hour each 
morning, last a certain time, and pass off. This is also true of the psy- 
choneurotic group, but the time of seizure and of relief is much less 
accurately recurrent. 

Headaches due to syphilis, to brain tumor, and to uremia are often 
worse at night, but syphilis has no monopoly of this characteristic. 

3. TWO TRADITIONAL FALLACIES ABOUT HEADACHE 

(a) The belief that physiologic and pathologic states of the 
female generative organs often produce headache is widespread. Text- 
books, such as Butler's, list dysmenorrhea, " uterine disease," disease 
of the ovaries, and even of the bladder ( !) as causes of headache. No 
proper justification for these ideas has yet been attempted, so far as I 
am aware. Headache is, of course, exceedingly common in menstru- 
ation, but so it is in eclampsia; yet no one to-day connects the eclamptic 
headache in any direct way with the condition of the uterus. Toxemia 
of the puerperium, toxemia of the menstrual period, is a much more 
plausible, though not a demonstrable, hypothesis. (For further evidence 
on this point see p. 83.) 

(b) " Lithemia " and " rheumatism " are also frequently invoked to 
explain headache. Neither word is defined by those who use them in 
this connection. " Lithemia " means constipation and the indigestion 
of lazy, gluttonous people, conditions which certainly do produce head- 
ache. (See ]). 35.) 



HEADACHE 



39 



" Rheumatic headaches " refer usually to the type associated with 
" stiff neck " and indurations in the bellies of muscles attached to the 
occiput or the temporal region. (See above, p. 36.) 

There seems, however, no sufficient reason for continuing the tradi- 
tion which applies the word "rheumatism" to such lesions. 

4. IMPORTANT TESTS 

The following tests should be made in all puzzling cases: 

1. Thorough examination of the eyes (including retinoscopy) , 
the pupil, and the testing of intra-ocular tension (glaucoma). 

2. Temperature record (infections), v ^ 

3. Blood-pressure measurement (nephritis, tumor). 

4. Urinalysis (albumin, sugar, acetone). 

5. Palpation of the insertion of the nape muscles at the occiput. 

6. Examination of the nose and its accessory sinuses. 

In the history, the following clues should be attended to: 

(a) Is the headache of paroxysmal occurrence and fixed duration 
(usually, twelve to twenty-four hours), accompanied by disturbances of 
vision and great prostration (migraine)? 

(b) Is the history that of a psychoneurosis? 

(c) Does the pain recur at precisely the same hour each day? 

Case 1 

A married woman of forty-two consulted me March 17, 1904, for long- 
standing headaches which had been present, off and on, during the last 
five years, since an attack of what was called ''grip/' followed by deaf- 
ness and ringing in the left ear. The patient lives in a very malarious 
part of a specially malarious suburb of Boston, but has never had the 
disease, so far as she knows. 

For the past year the headaches have "been much more severe, and 
have come with especial frequency at night, together with a burning 
'ion over the left side of the head, and to some extent over the entire 
1 ody, and accompanying this burning sensation she feels chilly, but the 
temperature has never been taken. The menopause occurred a yea' 
and since that time -he has noticed that she is getting stouter, that her 
skin is very dry, harsh, and sallov , velv any perspiration, and 

that her lips look bluish. Pain and the I coldness are often felt 

in the lower left axilla. Each winter old more and 

more. 

months ago she noticed •■ ' he feet and face; at the 



40 DIFFERENTIAL DIAGNOSIS 

present time there is none, but she gets out of breath upon the slightest 
exertion, and her heart then beats violently, rapidly, and irregularly. 
Her urine is thick, dark, offensive, and at times its passage is followed 
by vesical tenesmus. The headache often wakes her in the night, and as 
soon as she wakes she has to pass water, which gives relief to the head- 
ache. She thinks she passes more urine at night than in the daytime. 
She is very irritable, and has much twitching and quivering of the lips. 
Her only child was born ten years ago, and died within the first year. 

On examination the hands and lips were of a dark, slaty-blue color, 
yet quite warm. The face showed a yellow pallor, the total effect being 
that often seen under the Cooper Hewitt mercury light, such as is used 
in automobile garages. The heart was negative, save for a slight sys- 
tolic murmur at the base. The lungs showed nothing abnormal. The 
edge of the spleen was easily felt on full inspiration. Its consistency 
seemed increased. The abdomen was otherwise negative. The tem- 
perature was 99.2 F. at 5 p. m. The urine, save for high color and 
other evidences of concentration, showed no abnormality. 

Discussion. — The possibilities which were first considered in this 
case included cardiac disease, myxedema, malaria, and another presently 
to be mentioned. The diagnosis of the attending physician was "some 
queer kind of heart disease," but on examination I could find no heart 
disease, queer or otherwise, although the breathlessness and cyanosis 
made it natural to search for a cardiac lesion. 

Myxedema was suggested by the cutaneous changes and the sensi- 
tiveness to cold, but on cross-questioning neither of these two character- 
istics was at all well marked, and there were no mental changes, no sub- 
normal temperature and no special alteration in the physiognomy 
except as regards the extraordinary coloration before mentioned. It 
was easily made clear that this cyanosis did not depend upon any disease 
of the heart or lungs. The enumeration of the red cells showed but 
4,180,000, proving that the color of the lips was not due to polycythemia. 
There was nothing in the symptomatology nor in the gross character- 
istics of the feces to suggest a cyanosis of intestinal origin, nor did the 
coloration appear to be of the vasomotor type, so often seen in neurotic 
and hysteric patients. There was no ebb and flow about it, no varia- 
tion in the tint from hour to hour, nor from day to day. By rough tests 
there was no notable deafness and no mastoid tenderness. 

After excluding the causes above referred to, it was natural to think 
of methemoglobinemia, such as is often produced by overdose of head- 
ache powders containing acetanilid. Her attending physician had given 
her no such powders nor any diug belonging to the group prone to pro- 



HEADACHE 



41 



duce methemoglobinemia, but on questioning the patient I learned 
the following facts : For the last five years she had been taking headache 
powders in increasing numbers. Her husband obtained a box of them 
from the local druggist once or twice a week, and by calculation it 
appeared that she had averaged 100 grains a week for some months, 
great relief being thus obtained for the headache. 

A drop of her blood soaked into the bibulous paper of the Talqvist 
hemoglobin scale produced a chocolate-brown stain, quite incomparable 
with any of the hemoglobin tints of the scale. Spectroscopic examina- 
tion showed the familiar spectrum of methemoglobin. 

Outcome. — The patient was ordered at once to stop the headache 
powders and to take no medicine containing acetanilid or any member 
of that group. May 3d she reported that her headaches were much less, 
her sleep and breathing much better, and her sensitiveness to cold much 
less troublesome. She was still weak and pale, but her appetite was 
much improved, and she had gained eight pounds since March 17th. 

January 26, 1907, the attending physician writes me: "A year after 
you saw her the general condition was much better, although she occa- 
sionally had severe headaches. The color of the blood was improving, 
but at the time of the last examination which I made, a year after you 
saw her, blood still showed a tinge of brown." 

Diagnosis. — Methemoglobinemia. 

Case 2 

A longshoreman of thirty- six was first seen March 8, 1904. The 
patient has been in the habit of taking three glasses of whisky a day. 
He had gonorrhea at twenty-six, and chancre twelve years ago, followed 
by sore throat, a mucous patch, and an eruption. 

He had typhoid and pneumonia at thirty. Family history good. 

For a good part of the past live years he has had frontal headache. 
Last October he began to take potassium iodid, but in November 
the headache became worse, and a swelling appeared on the forehead 
over the left eye. The pain lasted a week and then disappeared A 
week ago, after being exposed to a violent draft on a sleeping tar, he had 
a similar attack. This lime his eyes WCTt dosed by a BWelling of the 
lid-. His forehead was tender and swollen, especially on the left. Now 
mplains of severe pain in the forehead, with BWelling and tenderness. 

I y< he- had what seemed like a similar process in the 

arpal bom- of the right hand, the bone becoming enlarged and 
\erv tender. Hi- general condition is now better than six inomh- 

He has taken potassium iodid, but finds that it makes the pain worse* 



42 DIFFERENTIAL DIAGNOSIS 

He has taken as much as 225 grains a day, but not regularly. His 
appetite is good, his bowels regular. He has had no symptoms of 
iodism, and feels perfectly well but for his headache. 

On physical examination the points mentioned in the history were 
verified, and nothing else was discovered. The second left metacarpal 
bone was much enlarged and irregular in outline. There were also 
enlargements at the base of the first phalanx of the left index-finger, 
and a slight rounded prominence over an area the size of an egg above 
the left eyebrow. The temperature ranged between 98 and 99.5 ° F. 
The leukocytes were 17,200 at entrance, 78 per cent, of them being poly- 
nuclear. The hemoglobin was 70 per cent., and the red cells showed 
a slight achromia. 

1. What further inquiries and examinations are likely to throw light 
on this case? 

2. What inferences can be drawn — (a) From the effect of a draft on 
the pain; (b) from the effect of potassium iodid? 

3. Why is eye-strain an unlikely cause for this headache? 

4. What points against frontal sinus disease? 

5. What three common chronic ulcerative processes involve the skin 
and deeper tissues most frequently. 

Further inquiry into the past history revealed the fact that he had 
had a chancre at twenty-eight, followed by a rash and a sore throat, 
with white patches in his mouth. A Wassermann test (not known in 
1904) would have helped toward diagnosis. 

Probably the "effect" of the draft was coincidence, at most, an 
exciting or favoring cause. Many headaches miscalled "rheumatic" 
are really syphilitic. There is no reason to believe that "rheumatism" 
ever causes headache except in acute infectious cases. The failure of 
potassium iodid is discussed below. 

Eye-strain does not often begin at thirty-six in a man who uses his 
eyes for such work as a longshoreman's. 

The long duration of the headache is against disease of the frontal 
sinus. Physical examination, however, must determine the point. 

Three common causes for chronic ulcerative processes (excluding 
varicose ulcer) are: Syphilis, tuberculosis, malignant disease. 

[The man was seen in consultation by Drs. Bowen, Shattuck, Fitz, 
Gannett, A. T. Cabot, and J. P. Clark. All concurred in the diagnosis 
of syphilitic periostitis.] 

Outcome. — The day after entrance two distinct craters about the 
size of a half-dollar were felt on the forehead. The headache was given 
some immediate relief by 10 grains of phenacetin with 2 of caffein, but 



HEADACHE 43 

sulphonal and trional, 10 grains each, were also needed for sleep. He 
was given inunctions of mercury and potassium iodid grains 10, increas- 
ing to 100. Black-wash was also applied to the forehead, and on the 
twelfth the iodid was omitted on account of marked swelling of the left 
eyelid. By that time the swelling of the forehead was much less, and 
after omitting the iodid, the swelling of the eyelid also became normal. 
By the fifteenth of March his symptoms had almost disappeared. Ob- 
viously, the mercury, rather than the iodid, was what helped him. He 
showed at no time any signs of salivation. 

In view of the above facts the diagnosis of syphilis is not in doubt, 
and needs no further discussion in this case. The relation of syphilis 
to headache seems to warrant us in dividing syphilitic headaches into 
three groups: 

(a) An acute infectious headache, occurring at or near the time of the 
roseola, adenitis, and other "secondary" lesions. 

(b) A chronic periosteal headache, with or without obvious external 
lesions on the forehead. 

(c) A headache with symptoms of brain tumor, due to localized syphil- 
itic processes within the skull, forming syphilomatous tumors or causing 
internal hydrocephalus. 

The latter group is of especial importance, since they are often 
mistaken for genuine brain tumor, whence follow a hopeless prognosis, 
a neglect of vigorous antisyphilitic treatment, and much unnecessary 
suffering. I have three times seen recovery after antisyphilitic treatment 
in cases given up to die of brain tumor. The only safe rule is: Give 
mercury (in moderate doses) and potassium iodid (in doses gradually 
becoming enormous) in every case presenting the signs and symptoms of 
cerebral tumor. 

The prognosis is for immediate relief and subsequent recurrence 
in one or another form. The expectation of life is much less than for 
non-syphilitics. 

Treatment — mercury especially should be given at intervals for 
life. Potassium iodid is needed only when definite Lesions are recog- 
nized. 

Diagnosis. — Syphilitic periostitis. 

Case 3 
A married Russian housewife of thirty-seven entered the: hospital 

17, [904. In [OO] she had been in the su: rds for 8 stric- 

ture of the rectum of inflammatory origin, for which an inguinal coloa 

to my was done After this operation >he had no trouble W 1th her bowels 



44 



DIFFERENTIAL DIAGNOSIS 



(which had been seriously constipated), the inguinal wound was closed, 
and she remained well until May i, 1904, when she began to have pain 
in the back of her head, at first mild, and relieved by "bromo-seltzer,' 
but for the past week very severe and extending over the whole head. 
It now lasts through the entire twenty-four hours, and has prevented 
sleep for the past two nights. Day before yesterday she had an attack 
of nausea and vomiting. The headache is so severe that she wants to 
jump through the window and kill herself. She feels first hot, then 
cold, sweats a great deal, especially at night, and easily becomes tired. 
Physical examination, including the fundus of the eye, shows nothing 
abnormal except an inequality of the pupils. Their reactions, however, 
are normal, likewise the blood and urine. 



<v*s^: 



fh 



,°uja_[sLk 



-Mit 



\%^ 



s 



<3 <3 <J2 <5 <s <5 



^1 



£& 



V 



Hi 



fefe!«?_L 



r<u* 



/ 



Fig. 2. — Chart of case 3. 

For the first two days her headache was continuous and severe, 
despite lactophenin, 10 grains, caffein, 5 grains, sodium bromid, 30 
grains, potassium iodid, 10 grains, three times a day. Compound jalap 
powder, 1 dram, and high enemas of oil and suds were given in the hope 
that the headache might be relieved by purgation. In spite of all these 
remedies the headache was undiminished at the end of the first week 
in the hospital. 

Discussion. — No certain diagnosis can be made in this case. The 
relief following potassium iodid may well be a coincidence, for many 
headaches of unknown origin subside without any treatment after a 
period similar to the course of this case. 



HEADACHE 



45 



The rectal stricture was of the type ordinarily regarded as always or 
usually syphilitic, but on insufficient evidence. There is no good 
histologic evidence for syphilis in such strictures, whereas it is well 
known that gonorrhea is prone to produce stricture in any tube. The 
presence of syphilitic lesions elsewhere in the body often gives color to 
the diagnosis of syphilis in a rectal stricture, but in this case there were 
no such lesions. 

The study of the previous history is of prime importance in the diag- 
nosis of such cases. It revealed in this case that the woman had been 
sterile, but had had no miscarriages and no lesions suggesting syphilis, 
so far as she knows. 

If the case is syphilitic, it is probably due to an intracranial lesion of 
the type simulating brain tumor. (See Case i, p. 39.) 

The prognosis is for immediate recovery, but probable recurrence, if 
the diagnosis of syphilis is correct, though the recurrence may involve 
any other organ (liver, aorta, bones, subcutaneous tissues). 

Antisyphilitic treatment should be continued at intervals for life. 
The interval depends on the character, circumstances, and physical 
condition of the patient. 

Outcome. — The potassium iodid was increased after the first week 
to 15 grains and then to 30 three times a day. The headaches had 
rapidly diminished in severity and frequency. Slight signs of iodism 
had in the mean time appeared. By the eighth of June she was feeling 
well and ready to go home. Three months later there had been no 
recurrence. 

Diagnosis. — Syphilis ? 

Case 4 

A married cloakmaker, forty years old, was seen June 21, 1894. 
Eight years previously she had begun to have womb trouble, charac- 
terized by bearing-down pain in the upper abdomen and back. Five 
years ago she had an accident to her head, and 17 stitches had to be 
taken. Since then she lias had unilateral "sick headaches" about 
four times a year, lasting usually one day. She has been pregnant six 
times, and has three times produced an abortion. 

□ to have pain in the hack of her neck, some 
darting, sometimi 1 Ln the day time, not preventing 

With the pain there seemed to l<c ;t Bwelling, which impn 

being both inside the throat and in the nape. She had no diffi- 
culty in BWallo her thr < -umewhat BOTC at the same 

time. Tl ctended to the whole head, affecting 



46 DIFFERENTIAL DIAGNOSIS 

especially the temporal regions, which feel swollen and tender. She 
has had no other symptoms. 

Physical examination showed the patient sallow and covered with 
a reddish, papular eruption, with a shot-like feel under the skin. It is 
most marked upon the face and trunk. Visceral examination is other- 
wise negative, as is the blood. •The urine is alkaline, high in color, 1023 
in gravity, with the slightest possible trace of albumin. The sediment 
shows large squamous epithelial cells in clumps, also polynuclear cells, 
triple phosphate crystals, and some octahedral crystals which resist the 
action of acetic acid. The fundus oculi is normal. 

Discussion. — Three types of headache are immediately suggested 
as we read the story of this patient: 

1. Due to trauma. 

2. Due to migraine. 

3. Due to syphilis. 

Traumatic headaches, following violent cerebral concussion, as in 
foot-ball or coasting, are apt to follow an initial period of coma, and 
usually persist steadily for weeks or months. Periodic pain, such as is 
here described, is not often associated with trauma. 

Migraine is apt to appear before the thirty-fifth year, and to occur 
more frequently than in this case. 

It is important to realize that unilateral periodic headache accom- 
panied by nausea and vomiting deserves the term "migraine" only when 
all known causes of headache can be excluded. The headaches asso- 
ciated with nephritis or cerebral tumor are often migrainoid in type, 
especially in the earlier stages of the malady. The study of the urine 
and of the fundus oculi is thus often omitted because the attacks are so 
described by the patient that "'typical migraine" is assumed and treated 
from the start. 

A migrainoid headache which later became constant, aroused, there- 
fore, the suspicion of nephritis and of cerebral tumor. Nephritis, how- 
ever, could be excluded in this case by the absence of urinary changes 
and of vascular hypertension. The fundus oculi was negative; there 
were no focal symptoms (such as aphasia, paralysis, Jacksonian or general 
epilepsy, paresthesia, or astereognosis), and the absence of vertigo, 
vomiting, and vascular hypertension also militated against the 
diagnosis of cerebral tumor, which, however, could not be absolutely 
excluded. 

Syphilis is suggested by the rash. Further examination showed a 
postcervical adenitis. The absence of any knowledge of infection is of 
no importance. Only positive evidence is of value in relation to syphilis, 



HEADACHE 



47 



and it cannot be too positively stated that in any person, young or old, 
rich or poor, whatever his character or circumstances, syphilis is always 
a possible diagnosis. The opportunities for the non- venereal acquisition 
of syphilis are very many. 

In this case the rash was not typical, but might have been an ordinary 
skin infection. Its generalized distribution, the associated adenitis, and 
the persistent headache made it, however, more suspicious. 

The absence of miscarriages is less significant, since the abortions 
may have anticipated the course of nature. On the whole, syphilis seems 
the most probable diagnosis. 

The prognosis and treatment of syphilis have been sketched on pp. 
43 and 45. 

Outcome. — The headache was relieved temporarily by 5 grains of 
phenacetin with § grain of codein. Later, some morphin was required on 
one or two occasions. Mercury and iodid of potash were given by 
mouth, in small doses, and in a week she was very much better. In 
two weeks the headache was very slight, the rash nearly gone, the glands 
barely palpable. July 12th she was discharged well, with the advice 
to continue the iodid of potash in 5-grain doses three times a day for a 
number of months. 

Diagnosis. — Syphilis. 

Case 5 

A Jewish shoemaker of thirty-seven was seen July 8, 1908. He has 
had some trouble with his stomach since he first came to this country, 
five years ago. Five days ago he began to have "pain over his heart," 
followed by shortness of breath and fainting. This attack lasted only 
a few hours, but since that time he lias had severe headache, loss of appe- 
tite, and gastric distress without vomiting. His bowels have become 
constipated, and his sleep is disturbed by bad dreams. 

On examination a few fine transient rales were found at the base 

of each lung. Respiration at the left base and axilla was somewhat 

louder than on the right. There was slight epigastric tenderness, and 

<>f the spleen was easily fell 1 ' inches below the costal margin. 

■• was anterior and internal bowing of the right tibia, with promi- 

\ but no roughening. The temperature at entranee was 100 F.J 

. 75; leu' 1 ere .}Soo; the W'idal reaction negative. Blood- 

Cultun egative; urine normal. 

Discussion.— What are the causes of prominence or enlargement ot 
the til 

of I he rah- in l! 



46 DIFFERENTIAL DIAGNOSIS 

especially the temporal regions, which feel swollen and tender. She 
has had no other symptoms. 

Physical examination showed the patient sallow and covered with 
a reddish, papular eruption, with a shot-like feel under the skin. It is 
most marked upon the face and trunk. Visceral examination is other- 
wise negative, as is the blood. •The urine is alkaline, high in color, 1023 
in gravity, with the slightest possible trace of albumin. The sediment 
shows large squamous epithelial cells in clumps, also polynuclear cells, 
triple phosphate crystals, and some octahedral crystals which resist the 
action of acetic acid. The fundus oculi is normal. 

Discussion. — Three types of headache are immediately suggested 
as we read the story of this patient: 

1. Due to trauma. 

2. Due to migraine. 

3. Due to syphilis. 

Traumatic headaches, following violent cerebral concussion, as in 
foot-ball or coasting, are apt to follow an initial period of coma, and 
usually persist steadily for weeks or months. Periodic pain, such as is 
here described, is not often associated with trauma. 

Migraine is apt to appear before the thirty-fifth year, and to occur 
more frequently than in this case. 

It is important to realize that unilateral periodic headache accom- 
panied by nausea and vomiting deserves the term "migraine" only when 
all known causes of headache can be excluded. The headaches asso- 
ciated with nephritis or cerebral tumor are often migrainoid in type, 
especially in the earlier stages of the malady. The study of the urine 
and of the fundus oculi is thus often omitted because the attacks are so 
described by the patient that "typical migraine" is assumed and treated 
from the start. 

A migrainoid headache which later became constant, aroused, there- 
fore, the suspicion of nephritis and of cerebral tumor. Nephritis, how- 
ever, could be excluded in this case by the absence of urinary changes 
and of vascular hypertension. The fundus oculi was negative; there 
no focal symptoms (such as aphasia, paralysis, Jacksonian or general 
epilepsy, paresthesia, or astereognosis), and the absence of vertigo, 
vomit [ar hypertension also militated against the 

;;.l tumor, which, however, could not be absolutely 
excluded. 

Syphilis is suggested by the rash. Further examination showed a 

al adenitis. The absence of any knowledge of infection is of 

no important e. ( >nly positive evidence is of value in relation to syphilis, 



HEADACHE 



47 



and it cannot be too positively stated that in any person, young or old, 
rich or poor, whatever his character or circumstances, syphilis is always 
a possible diagnosis. The opportunities for the non- venereal acquisition 
of syphilis are very many. 

In this case the rash was not typical, but might have been an ordinary 
skin infection. Its generalized distribution, the associated adenitis, and 
the persistent headache made it, however, more suspicious. 

The absence of miscarriages is less significant, since the abortions 
may have anticipated the course of nature. On the whole, syphilis seems 
the most probable diagnosis. 

The prognosis and treatment of syphilis have been sketched on pp. 
43 and 45. 

Outcome. — The headache was relieved temporarily by 5 grains of 
phenacetin with J grain of codein. Later, some morphin was required on 
one or two occasions. Mercury and iodid of potash were given by 
mouth, in small doses, and in a week she was very much better. In 
two weeks the headache was very slight, the rash nearly gone, the glands 
barely palpable. July 12th she was discharged well, with the advice 
to continue the iodid of potash in 5 -grain doses three times a day for a 
number of months. 

Diagnosis. — Syphilis. 

Case 5 

A Jewish shoemaker of thirty-seven was seen July 8, 1908. He has 
had some trouble with his stomach since he first came to this country, 
five years ago. Five days ago he began to have "pain over his heart," 
followed by shortness of breath and fainting. This attack lasted only 
a few hours, but since that time he has had severe headache, loss of appe- 
tite, and gastric distress without vomiting. His bowels have become 
constipated, and his sleep is disturbed by bad dreams. 

On examination a few fine transient rales were found at the base 
of each lung. Respiration at the left base and axilla was somewhat 
louder than on the right. There was slight epigastric tenderness, and 
the edge of the spleen was easily felt 1} inches below the costal margin. 
There was anterior and internal bowing of the right tibia, with promi- 
nence, but no roughening. The temperature at entrance was ioo° F.; 
pulse, 75; leukocytes were 4800; the Widal reaction negative. Blood- 
culture was negative; urine normal. 

Discussion. — What are the causes of prominence or enlargement of 
the tibiae? 

Significance of the rales in this case? 



50 DIFFERENTIAL DIAGNOSIS 

For the past two years she has had " sick headaches," beginning earl) 
in the morning or long after eating, lasting twenty-four hours, coming 
about once in two weeks, until lately, when they have begun to come 
twice a week and have been accompanied by nervousness. She feels 
hot most of the time, and prefers cold weather. For six months she has 
noticed a weakness of her hands. Two weeks ago she had the "grip," 
and has since then noticed considerable shortness of breath, amounting 
of late to orthopnea. She has lost 30 pounds in the last two years. 
The bowels have been slightly loose; the appetite excellent. 

Physical examination showed emaciation, cyanosis, a slight exoph- 
thalmos (not previously noticed by the patient) , a fine tremor of the hands, 
and marked asymmetric enlargement of the thyroid, its greatest circum- 
ference being 16 j inches. The heart's impulse was in the sixth inter- 
space, J inch outside the nipple-line, 4 inches to the left of mid- 
sternum. The action was rapid, ranging between 100 and 120, accom- 
panied by some irregularity. The first sound was very sharp at the 
apex, and was preceded by a presystolic roll. The pulmonic second 
sound was much greater than the aortic second sound. Systolic blood- 
pressure, 175 mm. Hg. Shadows and movements of the intestinal 
coils were visible over the abdomen. There was considerable tender- 
ness in the epigastrium and about the navel. The edge of the liver was 
felt 3 inches below the costal margin. There was no ascites, but both 
legs showed soft edema throughout. The leukocytes were 15,400. 
The blood was otherwise normal. The urine was pale, 1010 to 1012 in 
specific gravity, with a trace of albumin. There were many leukocytes; 
no casts. The. twenty-four-hour amount ranged between 15 and 30 
ounces. 

Discussion. — 1. What was the nature of the thyroid tumor? 

2. What caused the headache? 

3. Can any reason be given for her preferring cold weather? 

4. How are the characteristics of the urine explained? 

5. Is there more than one possible explanation of the presystolic 
roll heard in this case? 

6. Under what conditions are intestinal movements visible through 
the abdominal wall? 

7. What diseases produce loss of weight despite good appetite and 
digestion? 

The discussion of these questions will involve a statement of the diag- 
nosis, prognosis, and treatment 

Regarding the thyroid tumor, it is clear that its duration (thirty-six 
years) excludes malignant disease. We have left the so-called "simple 



HEADACHE 5 1 

goiter" and "exophthalmic goiter." The case illustrates well the 
transition from the first to the second condition; also the relation of the 
thyroid to pregnancy. From her eleventh to her forty-fifth year the 
patient had no symptoms from her goiter. It was increasingly unsightly, 
nothing more. Alter the forty-fifth year came the familiar symptoms 
of hyperthyroidism — loss of weight despite good appetite, a sense of 
increased bodily heat corresponding with the abnormally rapid metabol- 
ism; finally tachycardia, tremor, and exophthalmos. 

The only important diseases causing loss of weight despite good 
appetite are diabetes (either form), Graves's disease, and some cases 
of arteriosclerosis. In one of my cases of Graves's disease loss of 
weight was the symptom which brought the patient to me. He wanted 
to know why he was losing weight despite an excellent appetite. He 
mentioned no other complaints. 

In the present case the emaciation explains the visibility of intes- 
tinal peristalsis, for emaciation is all that is necessary to produce this 
symptom. In patients not emaciated such a sign usually means in- 
testinal obstruction. 

The condition of the urine in this case can hardly be explained 
(as one might at first think) as a result of renal stasis due to a dilated 
heart, for the low specific gravity and pale color are the opposite of what 
we expect in renal stasis. When taken in connection with the abnor- 
mally high blood-pressure, these features of the urine suggest nephritis. 
Such vascular hypertension is unusual in Graves's disease. The head- 
aches are also much more comprehensible if we suppose that the patient 
had both nephritis and Graves's. I have already referred to the fre- 
quency of so-called "sick headache" in nephritis, as well as in brain 
tumor and syphilis. In simple hyperthyroidism headache is not common. 

The cardiac signs suggest, first of all, a mitral stenosis with dilata- 
tion of the heart, but another possibility is to be remembered, namely, 
that the dilatation itself may be the cause of the murmur. It has been 
repeatedly noted of late that not only in connection with aortic regurgi- 
tation (the so-called Flint's murmur), but in any form of cardiac hyper- 
trophy and dilatation affecting the left ventricle, a presystolic roll may 
be heard at the apex. Thus in adhesive pericarditis and in simple 
nephritic hypertrophy we often hear such murmurs. There is no way 
of deciding in this case whether or not mitral Stenosi at, but it is a 

good rule, often borne out by postmortem experience, to assume as I 

in be made to explain the tacts. ( >n this principle, the diag- 
nosis of tl : hould be G e; < hronic nephritis with 
ilting < ardia< hypertrophy and dilai.it ion. 



52 DIFFERENTIAL DIAGNOSIS 

The prognosis is for a few months of life at best. . In treatment 
rest is the essential. Morphin, followed by bleeding, purgation, and 
diuretics, may give some relief. Digitalis is not likely to be effectual. 

Outcome. — The pulse-rate steadily declined during her first week 
in the hospital, and the swelling became less; but on January ist £he 
patient became noisy and mentally confused, the respiration slow and 
deep, the breath having an ammoniacal odor. There were frequent 
attacks of severe dyspnea. In the next thirty-six hours she was, for 
the most part, semiconscious, but never unconscious, and was com- 
fortable except during the attacks of dyspnea. Pilocarpin produced no 
sweating, and attempts to give a hot-air bath were unsuccessful. It was 
impossible to purge, as she refused to swallow anything. Her heart 
continued strong and not rapid. 

She died on the third of January. 

Autopsy showed chronic glomerulonephritis with hypertrophy and 
dilatation of the heart and general dropsy; simple adenoma of the 
thyroid; obsolete tuberculosis of the spleen. 

One of the interesting points in this case is the existence of nephritis 
without albuminuria during the period under observation. The blood- 
pressure gave more correct indication for diagnosis, as is often the case. 

Diagnosis. — Uremic headache; chronic glomerulonephritis; hyper- 
thyroidism. 

Case 7 

A young woman of twenty-five, a student, entered the hospital 
November 7, 1907. One of her aunts died of consumption. She was 
treated by Dr. R. W. Lovett for three years for some spinal trouble, 
beginning with her fifteenth year. When she was eighteen her menstrua- 
tion stopped and her spleen became enlarged. She was then treated for 
some time by Dr. Franz PfafT. Two years ago menstruation again 
ceased during the winter. The intervals between her periods are still 
five or six weeks long, and she always has headache during the cata- 
menia. She has been overworked for the past three years, and has 
been nervous, but has had no actual breakdown and no hysteric symp- 
toms; she has been especially tired most of the time since the first of 
October. She takes two cups of tea and one of coffee a day. 

Eight days ago she found it very hard to concentrate her mind upon 
her work. The next day she had severe headache, and that night was 
sleepless. Six days ago the headache became still worse, and she 
coughed up a little blood and phlegm. Ever since then she has coughed 
a little, but without sputa. Five days ago she had photophobia and felt 



HEADACHE 



53 



tender lumps upon the back of her head. That evening she had chill, 
followed by sweating. Three days ago she had another chill, and her 
teeth and her left ear ached. This time she began taking aspirin in 
5-grain doses for the relief of her headache, and found it very effectual. 
The last two days her headache has been less severe, but it is still present 
in the back of her head. She has been slightly constipated and has felt 
somewhat weak. 

Temperature, 101.3 F.; pulse, 83; respiration, 18. 

Physical examination was negative, save for a short, sharp, whistling 
systolic murmur in the pulmonary area, transmitted only along the left 



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side of the sternum. The abdomen was held slightly rigid throughout, 
but was tympanitic and free from tenderness. The spleen was not felt. 

Discussion. — Certain features in this case suggest that the head- 
ache may be due to tuberculous meningitis. The history of consump- 
tion in the family and of a prolonged treatment addressed to the spine, 
together with the cessation of menstruation at her eighteenth year, are 
all factors which make us think of tuberculosis. The photophobia, too, 
is a common meningeal symptom. 

ainsl meningitis, however, is the absence of any tuberculous focus 
now discoverable on physical examination, the absence of any lesions 

referable to the I :mial nerves, and the recent subsidence of the headache 

without an) 'Ik oming i oma. 



54 



DIFFERENTIAL DIAGNOSIS 



Could this be a neurasthenic headache, so called? She is at the age 
when such things are commonest, and there is a history of nervousness 
and overwork. But the continued fever seems to me to make this im- 
possible. I do not think there is any good evidence that a fever such 
as is shown in the accompanying chart ever results from neurasthenia, 
hysteria, or any psychoneurosis. 

Malaria is suggested by the chills and the headache, but is excluded 
by the absence of parasites in the blood. The lumps complained of in 
the occipital region were not discoverable on physical examination. 
Had they turned out to be glandular, syphilis might have been suspected. 

With the exclusion of the above possibilities we have to consider 
what diseases are the most frequent in patients who have fever with a 
negative physical examination and a low leukocyte count. The answer 
must, I think, be as follows : If the fever is a short one, it is generally 
labeled "grip" under these conditions, though I prefer to call it an un- 
known infection. If the fever persists for two weeks or more without 
the development of physical signs, typhoid usually turns out to be present, 
as was the case here. 

Outcome. — On the right side of the abdomen there developed later 
two red macules which decolorized on pressure. The course of the 
temperature is seen in the accompanying chart. The Widal reaction 
was positive at entrance. Blood otherwise negative. The course of 
her illness was uneventful, and she was discharged well on the seventeenth 
of December. 

It is worth emphasizing the fact that constipation, cough, and chills 
are common symptoms at the onset of typhoid, also that the headache 
is usually earlier and more prominent than in other infections. (For 
the treatment of this case see Appendix, p. 743.) 

Diagnosis. — Typhoid. 

Case 8 

A Russian clerk, eighteen years of age, entered the hospital February 
27, 1908. The only history which could be obtained from him was 
that two days ago he fell downstairs and since then he has had a good 
deal of headache. 

Physical examination showed that he was drowsy, his right pupil 
slightly larger than his left, both reacting normally. His throat was red 
and slightly swollen. There was considerable rigidity of his neck, but 
no actual retraction. Rotation and backward flexion were normal, 
but the head could not be bent forward. Visceral examination was 
entirely negative, with the exception of Kernig's sign, which was present 



HEADACHE 



55 



on both sides. The temperature was 100.3 ° F.; the pulse, 60; respira- 
tion, 25. Fundus oculi normal. Blood and urine normal. Blood- 
pressure, 145. During the night he became unconscious, and the next 
morning had marked retraction of the head, unequal and unresponsive 
pupils, a strabismus, absence of superficial reflexes, Babinski's reaction 
on the right, and a rectal temperature of 102.8 ° F. • 

Discussion. — Concussion of the brain and meningitis were the diag- 
noses at first suggested in this case. Any headache following a fall on 
the head is rightly suspected as being due to concussion, but there are 
certain symptoms in this case not thus to be explained, i. e., the 
inequality of the pupils, the rigidity of the neck, and the presence of 
Kernig's sign. 

These three signs, together with the presence of fever and slow pulse, 
the rapidly developing coma, strabismus, and Babinski's reaction, all 
point to meningitis, which was the diagnosis made at the outset. 
Acting upon this a lumbar puncture was done, and 35 c.c. of bloody, 
turbid fluid were removed. The examination of this fluid, however, 
showed nothing but macerated red corpuscles, no micro-organisms 
either in cover-glass or culture. This speaks strongly against epidemic 
meningitis, while the great rapidity of onset and the absence of any 
lymphocytosis in the spinal fluid make tuberculous meningitis unlikely. 
The presence of blood in the spinal fluid suggests cerebral hemorrhage 
or fracture of the base of the skull. 

Normal urine and normal blood-pressure rule out uremia, and nor- 
mal blood excludes malaria. Brain tumor may manifest itself suddenly 
after a long latent period by symptoms like those in this case, but the 
absence of paralysis, of changes in the fundus oculi, and the presence of 
the rigid neck and the bloody spinal fluid militate against this diag- 
nosis. Xo absolute decision was arrived at before death, which oc- 
curred on the first of March. 

Outcome. — Autopsy, March 1st, showed fracture of the base of the 
skull, multiple contusions of the cerebellum and frontal lobes, with 
hemorrhage. 

Diagnosis. — Fracture of the base of the skull. 

Case 9 

A domestic of twenty-three was seen March 14, 1908. She was 
perfectly well until noon of the day before, when she was seized with 

shaq>, cutting pain in the forehead and a slight sore throat, with fever. 
She went to bed and slept well, h with the same headache, and 

vomited when she got out of bed. The headache has continued since. 



56 DIFFERENTIAL DIAGNOSIS 

When seen at the hospital the patient's temperature was 102.5 ° F.! 
her pulse, 125, the skin hot and dry. The pupils were equal, regular, 
and reacted normally; the fundus negative; the throat slightly reddened 
and swollen; face flushed. The viscera, negative. Leukocytes, 9000. 
Blood and urine were otherwise normal. Blood-pressure, 125. During 
the first thirty-six hours of her stay in the hospital she suffered a good 
deal with headache, relieved more or less by phenacetin and an ice-bag 
in the frontal region. 

Discussion. — I have known tuberculous meningitis to manifest 
itself first by intense pain at the root of the nose, as in this case. All 
the ordinary symptoms of that disease, however, except headache and 
fever, are absent in this case. Typhoid, malaria, and most other infec- 
tions are ruled out by the negative physical examination and the short 
course of the disease, which was practically gone in four days. On the 
third day careful questioning showed that the pain was limited to the 
region of the frontal sinuses. On the eighteenth she was able to go back 
to work. 

In view of these facts an infection of the frontal sinus seems the most 
likely cause of her headache. In some cases of this disease the head- 
ache appears in a characteristic way at the same hour each morning, 
perhaps owing to the accumulation of secretions during the night. 
Sometimes the diagnosis is assisted by the sudden appearance of a nasal 
discharge coincident with the cessation of pain; in other cases the close 
limitation of the pain to the region of the frontal sinuses is our best clew 
to diagnosis. 

Outcome. — On the eighteenth of March she went back to work. 

Diagnosis. — Sinusitis. 

Case 1© 

A cook of twenty- three entered the hospital April 9, 1908. Her 
family history and past history were excellent. Two months ago she 
stopped work for a fortnight because of fatigue and persistent headache. 
Ten days ago the headache returned and has persisted since. It is 
severe in the frontal and occipital regions. Four days ago she began 
to vomit, and since then has vomited about six times every twenty-four 
hours. Even water is rejected. There has been no abdominal pain, 
but persistent nausea. She has had no cough and no other symptoms. 
The course of the temperature is seen in the chart on page 57. 
The white cells were 4400 at entrance, 4900 on April 20th; the Widal 
reaction always negative; the blood otherwise negative. The urine 
ranged between 20 and 30 ounces in twenty-four hours, with a specific 



HEADACHE 



57 



jk£_ 



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iug 



??z??S??zp 




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gravity between 1026 and 1036; a trace of albumin; a few hyaline and 
fine granular casts. The pupils were equal and reacted to light and 
distance; the fundus oculi, normal; the chest and abdomen negative, 
save for slight tenderness and rigidity in the epigastrium. During the 
first week she seemed rather hysteric at times, complained continually 
of headache, and was hungry, but no diagnosis could be made. 

Discussion. — Typhoid is suggested by the course of the tempera- 
ture, the subnormal leukocyte count, and the headache. Indeed, there 
is nothing in the case, as here stated, positively to exclude typhoid. 
Against it, however, are the long duration of the headache, which is 
usually gone after the first ten days in typhoid. The persistent nausea 
is also very unusual in typhoid. Per- 
haps the strangest symptom, however, 
is the excellent appetite, which is al- 
most unknown in a patient seriously 
sick with typhoid. 

The question of hysteria must be 
considered. All the symptoms in the 
case are consistent with this diagnosis, 
with one exception — the continued 
fever. There is, in my opinion, no 
such thing as a hysteric fever of this 
type. An elevation of less than one 
degree over a considerable period or a 
sharp sudden, short-lived rise occurs in 
hysteria, but not a persistent fever of 
this type. 

The two diseases seriously to be 
considered are cerebral syphilis and 
tuberculous meningitis. As a matter 
of fact, the diagnosis of syphilis was made in this case by a skilled 
neurologist. The entire absence of any history and of any visible lesions 
of this disease is not in itself at all conclusive against it, neither is the 
i the patient, although the greal majority of cases of cerebral 
syphilis occur in older persons. More important evidence against 
Syph0]8 is the subnormal leukocyte count, which is distinctly rare in 
syphilitic 

Epidemic meningitis COmeS On more suddenly, almost always pro 

a leukocytosis, and usually runs a shorter course. Nevertheless, 

it cannot be excluded without an examination of the spinal fluid. 
Outcome. — April 226 lumbar puncture was done, ;ind 



I' ig. 4. ( 'hart of 



:o c.c. 



Of 



58 DIFFERENTIAL DIAGNOSIS 

clear pale fluid was obtained, the sediment showing 72 per cent, of 
lymphocytes, 28 per cent, of epithelial cells. In the Thoma-Zeiss coun- 
ter, this fluid showed 42 lymphocytes per c.mm. On the twenty-third 
the patient seemed to be restless, the left pupil slightly larger than the 
right. During the forenoon the left hand became flexed. At noon, the 
left leg and the left side of the face became paralyzed, and the reflexes 
absent. Syphilis, producing softening from thrombosis in the region 
of the right internal capsule, was suspected. The patient soon after 
became semicomatose. The head was drawn sharply to the right. At 
times the patient would recognize and talk with her relatives, and is even 
able to move the left arm and leg. 

On the twenty-fourth knee-jerk of the right leg disappeared, and a 
pin could be passed through the skin of either leg without pain. 

On the twenty-fifth there was left lateral conjugate deviation with 
lateral nystagmus, more constant in the right eye. Respiration became 
labored. Edema appeared in the hands, and the patient died at noon 
on the twenty-fifth. 

Autopsy showed miliary tuberculosis of the lungs and spleen; tuber- 
culous meningitis; tubercular ulcers of the ileum; tuberculosis of the 
retroperitoneal glands. 

It should be distinctly stated that cases of proved tuberculous menin- 
gitis have recovered. Probably this outcome takes place in less than 1 
per cent, of the cases, but it is important to know that it is possible. 

Diagnosis. — Miliary tuberculosis. 

Case 11 

A house-painter of forty-two entered the hospital December 4, 1907. 
He is in the habit of taking three drinks of whisky a day, but has had 
no previous illness. A year and a half ago he began to have headaches, 
vertigo, cramps, and vomiting; was sick for three or four days. He 
was treated in the Somerville Hospital for five weeks, but did not im- 
prove much, and has been unable to work since. He is now troubled 
much with occipital headache, worse in the morning and after he has 
been drinking. He now rarely vomits. Last night he had a nosebleed. 
He has had no abdominal pain of late. He has had occasional night- 
sweats, but none for two weeks. Headache is his chief complaint. 

Physical examination of the chest is negative except for a short 
systolic murmur at the apex of the heart and accentuation of the aortic 
second sound. The pulse tension seemed to be high. The blood-pres- 
sure was 160 mm. Hg. On the right side of the abdomen, at the level 
of the navel, a smooth, rounded, slightly tender mass is felt. The 



HEADACHE 



59 



patient subsequently said that he had had blood in his stools for fifteen 
or sixteen weeks, averaging a gill a day. An expert proctoscopic ex- 
amination showed no sufficient cause for this blood. On examination 
in a warm bath the tumor previously described was much easier to feel. 
It appeared to be about the size of a grape-fruit, and connected with 
the kidney. The urine was about 30 ounces in twenty-four hours, 
milky, 1 01 3 in specific gravity, the sediment containing a large amount of 
pus, and an occasional granular cast. The hemoglobin was 70 per 
cent. 

Profuse bleeding from the rectum continued, and vomiting of large 
amounts of green material with a little fresh blood happened several 
times. The right lung was full of coarse moist and dry rales. X-ray 
showed a shadow, probably of stone in the right kidney. The profuse 
intestinal hemorrhage suggested malignant disease, but no other evi- 
dence of it could be found. The amount of urine passed became 
smaller and smaller. On the seventeenth of December the sputum 
became bloody and the patient continued to vomit blood and to pass it 
by rectum. Numerous purpuric spots appeared on the skin. He 
sweated profusely in the hot-air baths and seemed better after them. 

Discussion. — Although the patient is somewhat alcoholic, there 
certainly is not enough evidence to make us believe that whisky is the 
cause of his sufferings. 

Lead-poisoning is naturally suggested by the patient's occupation, 
by the history of abdominal cramps, and headaches. If lead-poisoning 
were present, it might also account for the renal symptoms and for the 
rather high blood-pressure. As a matter of fact, the patient was treated 
for five weeks for lead-poisoning, and the fact that he did not improve 
during that time is, in itself, against the diagnosis. More important, 
however, is the tumor above described, which cannot possibly be ex- 
plained by lead. The presence of this tumor, together with the pus in 
the urine and the results of x-ray examination, point strongly to stone 
or tuberculosis of the kidney. The headaches, pains, and sweats are 
quite explicable if there is suppuration of tuberculous or calculous 
origin in the renal pelvis. 

We have still to explain in some way the mysterious hemorrhages 
from the rectum, stomach, and respiratory tract. The accentuation of 
the aortic second sound, the blood | , die low specific gravity <>f 

the urine, and its constantly diminishing amount sui" Qcomitant 

nephritis. 

Outcome. — Operation was considered, but postponed, owing to the 

man's poor condition. D ring the last two days <>f life he passed practi- 



6o 



DIFFERENTIAL DIAGNOSIS 



cally no urine. He was irritable and unreasonable, his mind wandering. 
He died on the twenty-second of December. 

At autopsy the right kidney was found to contain a very large stone 
and several smaller ones. Three-quarters of the organ was converted 
into a bag of pus, and the remaining portion showed as cystic degenera- 
tion. The left kidney showed the lesions of chronic glomerulonephritis. 

Diagnosis. — Stone in the kidney with abscess and nephritis. 

Case 12 

An electrician of thirty- three entered the hospital September 10, 1907. 
He was perfectly well until two weeks ago, when he began to have 



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severe, shooting pain in the forehead, spreading to the rest of the head. 
His face was puffy and red every forenoon and his hands became swollen. 
Yesterday he became very dizzy and could hardly see to walk, but did not 
fall. He lost three pounds in two weeks and is thirsty and nervous. 

The patient was semicomatose and answered no questions. He 
moved restlessly upon the bed with his eyes shut and his hand to his 
head. He was not asleep or drunk, and there was no evidence that he had 
been drugged. 

On examination, the face was distinctly puffy. The muscles about the 
eyes twitched involuntarily from time to time. Fundus oculi negative. 
The incisor teeth were worn down — the patient says because he grinds 



HEADACHE 6 1 

them at night. The spleen was not" palpable. Physical examination 
was otherwise negative. Blood-pressure, ioo mm. Hg. Temperature, 
102.6 F. White cells, 3400. Urine negative. The blood showed 
no malarial organisms. The symptoms seemed to point strongly toward 
uremia at the time of entrance, but the urine was absolutely negative. 

At entrance the patient was put into a hot bath, but collapsed twenty 
minutes later, his blood-pressure being very low. 

Discussion. — Nephritis is suggested by the drowsy condition, the 
edema of the face and hands, and the headache. The negative urine 
does not necessarily exclude chronic nephritis, but the low blood-pressure 
and the normal size of the heart are strongly against this diagnosis. 

Brain tumor is suggested by the headache, the vertigo, and the 
drowsiness. Against it are the negative fundus examination, the low 
blood-pressure, the absence of focal symptoms. 

Migraine may produce syrup toms similar to those in this case, but 
one almost never sees a patient of thirty-three in his first attack of 
migraine, and this patient had had no previous attacks like this. 

There is no evidence of reflex causes. In fact, the diagnosis was not 
suspected until the fall of temperature to normal next morning, and its 
subsequent rise on the succeeding day suggested malaria. 

Outcome. — On the fourteenth he had a chill. The blood showed 
a number of fully grown malarial parasites. Under quinin the patient 
was well within a few days. 

Diagnosis. — Malaria. 

Case 13 

A Russian housewife of fifty-eight entered the hospital November 30, 
1906. She entered the hospital first in April, 1906, suffering from 
"interstitial myocarditis " with paroxysmal tachycardia. She was next 
seen on the thirtieth of November; her physician states that since leaving 
the hospital she has had attacks of tachycardia every few weeks, the 
attack usually lasting two days and often accompanied by headache. 
Between attacks she felt well; her appetite was good, her bowels regular, 
there was no loss of strength. 

Nine days ago she began to have constant headache, precordial dis- 
. insomnia, and anorexia. There is now no cough and no dyspnea, 
but she feels weak and tired. 

Physical examination showed Blight pallor and marked pulsation 

in the neck. The left border of cardiac dulness was six inches to the 
left of the midsternum in the fifth ipace, the right border one inch to the 



62 



DIFFERENTIAL DIAGNOSIS 



right of midsternum; sounds rapid, but regular; the first apex sound 
sharp; the second, barely audible; a rhythm like that of the fetal heart, 
the rate something over 190. All the heart-beats were transmitted to 
the wrist, though the tension was low. 

Physical examination was otherwise entirely negative. During the 
first part of her stay in the hospital the tachycardia showed only slight 
remissions, sometimes for a minute, sometimes for several hours. The 
rate did not seem to be affected by sleep, talking, or food. Digitalis 
had no effect. Tincture of aconite had no effect. Except for weak- 
ness and some mental anxiety, the patient seemed well. 

Discussion. — Although the headache was much complained of in 
this case, it was at once thrown into the background by the general 



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physical examination, which made tachycardia prominent. Our chief 
problem is to interpret the tachycardia existing in this case, more espe- 
cially as regards prognosis, which is always the essential point in tachy- 
cardia. 

Cases of paroxysmal tachycardia may be divided, into three groups: 

(a) Those having an obvious exciting cause. 

(b) Those occurring in the course of a chronic cardiac disease. 

(c) Those of whose origin we have no idea. 

The first and the last of these groups carry a good prognosis. For 
practical purposes this is the most important point. I was once sum- 



HEADACHE 63 

moncd in hot haste to the bedside of a woman of forty, where I found 
the family assembled awaiting her death. The attending physician 
thought she had but a few hours to live. Her pulse was 210, her heart 
action absolutely regular and of the fetal type, her heart not enlarged, 
her breathing slow and easy in a recumbent position. The tachycardia 
had come on six hours previously, during a family quarrel, the patient 
being partly drunk. 

Vigorous reassurances were given to the family in the patient's 
hearing, but without addressing her. Within an hour the tachy- 
cardia ceased. 

I have seen a similar attack in a high-strung young girl who was in 
the dentist's chair during menstruation. The dentist \tas excessively 
alarmed, as the pulse was over 200 and barely perceptible, but the 
patient was as well as usual next day. 

Attacks may follow a gastric upset or come after a surgical operation. 

Tachycardia of this type occurring in patients who have definite 
signs or history of cardiac insufficiency, whether from valvular or myo- 
cardial lesions, are more serious, but I have never known a patient to die 
during or soon after such an attack. The prognosis is that of the under- 
lying lesion, and is not appreciably modified by the occurrence of tachy- 
cardia. 

Treatment. — Some cases are immediately relieved if the patient is 
placed head downward for a few seconds; others have been known to 
recover immediately after by drinking ice-water after emptying the 
stomach or after moderate exercise. Drugs have no obvious effect. 

Outcome. — On the twelfth of December the tachycardia ceased 
during the night, and on the sixteenth she had two days without any. 
From this point on the attacks grew shorter and occurred at longer inter- 
vals. There was no evidence that they were influenced in any way 
by any drug or other treatment given her, and she left the hospital much 
relieved, on the third of January, though the myocardium still showed 
evidence of weakness. 

Diagnosis.— Paroxysmal tachycardia complicating a chronic myo- 
cardial insufficiency. 

Case 14 

A school-boy eight years old entered the hospital May 16, 1907, 

Since early childhood he and his brother and his sister have had 

vomiting spells ab e a month. In such a spell he goes to bed 

the night, is feverish and sleepy the next day; after 

thai he Is perfectly well. It is Burmised that 1! ts are due to 

ing too much < andy. 



6 4 



DIFFERENTIAL DIAGNOSIS 



Five days ago he had headache and fever and vomited once. The 
headache and fever have continued since, and he has been unable to go to 
school. He has had a slight loose cough, but no expectoration. Last 
night he slept poorly and complained of epigastric pain. The course of 
the temperature is seen in the accompanying chart (Fig. 7). 

Physical examination of the head, neck, and heart was negative. 
The abdomen was slightly distended, tympanitic, firmly held, and very 
tender throughout. The child breathed rapidly, with short, groaning 
expiration. He was admitted to the hospital with a diagnosis of acute 
appendicitis. The right lung showed dulness 
from the apex to the fourth rib in front and 
over the entire back, associated with bronchial 
breathing, increased voice, and fremitus. 

Discussion. — I have known several cases 
like this operated upon for appendicitis owing 
to the lack of a thorough physical examination. 
Especially in children it is essential to make a 
thorough examination of the chest whenever the 
presenting symptom is abdominal pain. The 
backs of the lungs are often not thoroughly 
examined, because we shrink, very naturally, 
from having a patient sit up or even turn upon 
his side; but in a case of this kind this is a short- 
sighted kindness. 

Outcome. — On the twenty-second the tem- 
perature reached normal and the patient felt 
finely. On the twenty-fifth the temperature 
again rose, and the white cells, which had been 35,000 at entrance, were 
found to be still at approximately the same figure, with 92 per cent, of 
polynuclear neutrophiles. 

When fever persists in a case of this kind and the percussion dulness 
does not clear up, one of three possibilities is generally entertained: 
One thinks of an unresolved pneumonia, of a pleural thickening, or of 
postpneumonic empyema. In nine cases out of ten the latter turns out 
to be the true diagnosis. Unresolved pneumonia is mostly a myth. In 
the vast majority of cases it spells empyema. Pleural thickening causes 
no such elevation of the leukocyte count. 

A needle introduced at the right base drew pus containing poly- 
nuclear leukocytes and pneumococci. 

Diagnosis. — Infection (post-pneumonic empyema). 



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HEADACHE 



65 



Case 15 

A little girl of fifteen, a chocolate dipper by trade, entered the hospi- 
tal December 27, 1900, complaining chiefly of headache, which she has 
had for three days. It has been accompanied by some aching of the 
feet, general fatigue, and weakness. Her appetite has been good, but 
her food has been frequently vomited. She has had to stay in bed for 
the past three days. The course of her temperature is seen in the accom- 
panying chart (Fig. 8). 

Physical examination showed good nutrition, flushed face, heavy 
eyes, pupils equal and reacting, tonsils enlarged and red, a soft, sharply 
localized systolic murmur at the apex of the heart; the spleen palpable 
on inspiration. The internal viscera were otherwise negative; the first 
phalanx of the right ring-finger was a 
little red and swollen. On the ulnar side 
there were a patch of granulation tissue 
and a large bleb, from which pus could be 
expressed. From the history and spleen 
typhoid seemed to be the most probable 
diagnosis. 

The 'Widal reaction was absolutely 
negative. White cells, 11,000. There 
was a diazo-reaction in the otherwise 
negative urine. The headache continued 
very troublesome. 

On the night following entrance the 
patient complained of a little pain in her 
right knee, the inner side of which was 
found to be very slightly swollen and 
tender, not red or hot. The next three 
or four days there was the same com- hi %' 8 -~ chart « f <** *5- 

plaint at the same time every night. The knee gradually became more 
swollen, and there was a suggestion of floating of the patella. 

Discussion. — In the early days of this case, with headache, high 
fever, and nothing to show for it, it was probably impossible to make a 
definite diagnosis. The presence of the heart murmur suggests an endo- 
carditis, with or without general sepsis. Such infections arc very com- 
mon in girls of this age. The white count of 11,000 is somewhat against 

this; the condition of the ring finger favors it. 

Typhoid seems more probable in many respeets. The history and the 

enlargement of the spleen especially favor thai diagnosis, and the diazo- 
reaction would be generally considered confirmatory evidence, while the 




66 DIFFERENTIAL DIAGNOSIS 

absence of the Widal reaction by no means excludes typhoid. In fact, 
the only decided evidence against typhoid during the early days of her 
illness was the leukocyte count. 

The headache and splenic enlargement are quite consistent with 
malaria, but the time of year makes this unlikely and the blood examina- 
tion excludes it. 

With the appearance of pain in and about the right knee thirty-six 
hours after entrance a new crop of possibilities springs up. Rheumatic 
arthritis or gonorrheal arthritis comes first to mind. The fact that only 
one joint is involved is against ordinary "rheumatism," and in any type 
of arthritis we should expect more pain when the fever and constitutional 
manifestations are as marked as in this case. 

I have recently seen a case of trichiniasis with symptoms a good deal 
like those in this case, and absolutely without eosinophilia during the 
first week under observation. In this case the diagnosis was made by 
finding the trichinella embryo in the peripheral blood. 

Osteomyelitis should always be considered in a case presenting the 
symptoms here described. It is not at all unusual to have the fever and 
constitutional manifestations precede, by a considerable interval, any 
localization of the process. We get strongly the impression that the 
infection is first general and later local. 

Occasionally we see a case beginning exactly like this one, but going 
on to rapid recovery without ever presenting symptoms any more definite 
than those here described. We have then to be content with surmising 
that some low-grade infection has been overcome. 

Outcome. — On January 2d the temperature was still high, and the 
knee intermittently painful. At times the patient awoke from sound 
sleep complaining bitterly of knife-like pain in her knee. The swelling 
increased over the inner condyle of the femur, where there was also the 
greatest tenderness. There was no cording of the veins, no glandular 
enlargement or tenderness, no edema of the leg. 

January 6th: "The swelling of the knee has been increasing. The 
whole leg is now somewhat swollen. At the knee it measures ij inches 
more in circumference than the left. The patella now floats. Leuko- 
cyte count is now 16,000. At entrance it was only 11,000. The tem- 
perature is also lower, and in the past two days there has been some de- 
crease in the swelling. There was a diazo-reaction in the urine at the 
time of entrance, and this has persisted since. 

" January 9th: Pain in and around the knee has been very severe in 
the last three days. The leukocyte count is now 19,300." 

January 10th : Incision over the outer condyle of the femur liberated 



HEADACHE ^_ 67 

two ounces of greenish staphylococcus pus. Three perforations were found 
in the periosteum at the lower end of the femur, with pus all around the 
bone. The bone was opened and pus found in the lower epiphysis and 
the lower end of the shaft. Convalescence normal. 

Diagnosis. — Staphylococcus infection (osteomyelitis). 

Case 16 

A laborer of thirty-six entered the hospital September 25, 1906. 
For three years he has complained of indefinite stomach symptoms. 
For sixteen months these symptoms have been more marked, but have 
not amounted to actual pain, though they have been severe enough to 
prevent his working ; there has been no vomiting. During these sixteen 
months he has had fairly constant headache, not localized, not very 
severe, but often accompanied by vertigo. A year ago he was so sick 
that he was in bed four months, after which he was much improved, and 
has Dot been in bed since. 

His bowels move from one to three times a week, and only with 
purgatives or enemata. He has no appetite and has lost about thirty 
pounds. He has had many doctors, many diagnoses, and much treat- 
ment. He denies alcoholic excess and venereal disease. 

Physical examination shows slight irregularity and sluggish reactions 
in the pupils; the left is larger than the right, and there is right external 
strabismus. There is a well-marked tremor of the tongue when pro- 
truded, and at times his lips are tremulous, as are his hands. The edge 
of the liver is palpable on deep inspiration. The knee-jerks are lively, 
Achilles jerk normal. White cells, 12,000; urine normal. Gastric 
examination with the stomach-tube showed the lower border of the 
organ reached two inches below the umbilicus; its functions and secre- 
tions appeared to be normal. Visceral examination otherwise negative. 

Under daily lavage and Zander treatment with vibrations he showed 
some improvement. He took a good deal of exercise and gradually 
acquired a good appetite. 

Discussion. — The questions which we naturally ask ourselves in 
this case are as follows: 

1. Can this be a "neurasthenic" headache? 

2. Can it be due to eye -train? 

3. Has it any connection — (a) With the ^astrcctasis or (b) with the 
pupillary chan 

A "neurasthenic " headache i. e, t one of unknot n cause and \x i 
outcome — is suggested by the !• le of the symptoms, by the ab- 

• and viscera] lesions, and by the apparent nervousness 



68 DIFFERENTIAL DIAGNOSIS 

manifest in trembling of the lips and hands. But against this hypothesis 
is, in the first place, the fact that he is a day-laborer and has, therefore, 
no right to such troubles unless under the influence of alcoholism or some 
severe and obvious mental strain. Further, this hypothesis does not 
explain the irregularity and sluggishness of the pupils nor the tremor of 
the tongue. 

Eye-strain causes chronic headache, and the strabismus here present 
might well be a favoring cause. How long that strabismus has existed the 
patient has no idea, but it is certainly a very old affair as compared with 
the headache. Again, it is inherently unlikely that a day-laborer should 
begin to suffer from eye-strain at thirty-three. The point could only be 
definitely settled by a more accurate examination of his eyes. 

Dementia paralytica is distinctly suggested by the association of 
pupillary defects with the tremor of the tongue and lips and the chronic 
headache. The absence of a syphilitic history does not exclude the 
existence of that disease. We might expect more change in the reflexes 
and more obvious mental symptoms, but these are by no means neces- 
sary. The diagnosis could be made much more certain in case the 
spinal fluid obtained by lumbar puncture contained an excess of cells 
with a lymphocytosis. 

Outcome. — By the eleventh of October his stomach ceased to trouble 
him, but he showed a marked lack of initiative; he was perfectly content 
to sit and gaze absent-mindedly at nothing in particular. He expressed 
himself as greatly improved, and had gained a couple of pounds. It 
was subsequently ascertained that he had been in an insane asylum in 
November and December, 1905. There they obtained a history of con- 
vulsive attacks, said to be brought on by eating, and characterized by 
twitching of both arms, with numbness of hands, occurring daily for 
about a week and lasting something less than an hour. During these 
attacks he was sometimes unconscious, and after coming out of them, 
failed to recognize people for a considerable time. 

While at the asylum his eyes showed typical Argyll -Robertson 
pupils. The knee-jerks were exaggerated, and there was a Babinski 
reaction on the left, with marked incoordination of the upper extremities 
and in the gait. Examination of the eyes was entirely negative. Men- 
tally, he seemed more cheerful than the situation justified. 

Diagnosis. — Dementia paralytica. 

Case 17 

A widow of seventy-three was seen March 8, 1907. She had a fall 
at twenty-one, was hurt inwardly and doctored for ten years. She had 



HEADACHE 69 

"brain fever" at twenty-four, and was four months in bed. Ten years 
ago she had an attack similar to the present one, but less severe. She 
has become very nervous in the last few years. Six weeks ago she was 
taken with sharp pain in the eyes, spreading later to the top of the head 
and the left side of the face, sometimes shooting along the jaws or behind 
the ears. The pain has been steady during these weeks — at times sharp 
enough to make her cry out. Light hurts her eyes. Cold increases 
the pain, and her jaw is so painful that she cannot chew. 

Physical examination showed obesity, but was otherwise negative. 
When the patient's attention was turned from herself, she seemed to 
be perfectly happy. One night she kept the whole ward awake because 
of an indefinite fear that something was going to happen to her. 

Discussion. — In this case, as in the last one, dementia paralytica 
is suggested, but there is really very little to support that supposition. 
The tremors and pupillary signs present in the last case are quite absent 
here. 

Although the pain here started in the eyes, there is nothing else in the 
case to suggest eye-strain, and as the suffering has not been closely lim- 
ited to the region of the frontal sinuses, we have no good reason to sup- 
pose any inflammation there. 

In genuine neuralgia we cannot ease the pain by diverting the pa- 
tient's attention. 

On the whole, the headache seems to be one of that large class of 
mysteries from which we divert our attention because we are unable to 
give them a name and because they pass off fairly quickly. No doubt 
in this case the psychic condition was in some way an important cause. 

Outcome. — On examination by an eminent alienist she showed no 
proof of insanity, but was believed to be a nervous, hypochondriac, 
weak-minded old lady. Magnesium sulphate, i\ ounces daily, seemed 
to do her good. She was easily controlled by reason and by appealing 
to her better nature. Since the first night when she raised the roof for a 
time she had no bursts of temper or loss of self-control. The pain 
did not seem to mean much, and she was discharged on the nine- 
teenth. 

Diagnosis. — Headache of unknown origin. 

Case 18 

An Irish housewife of twenty three entered the hospital April 30, 

1007. She was confined eighteen days ago, the labor being accompanied 

by a large loss of Mood. At the end of a week she complained of a 

ide of her face; later in the other side as well, but was 



7° 



DIFFERENTIAL DIAGNOSIS 



able to get up and take care of the baby. Last night the doctor found 
her in a slight stupor, which has increased during to-day. The course 
of the temperature is seen in the accompanying chart (Fig. 9). 

The patient was semicomatose, had considerable pigmentation of 
the face and neck, normal pupils, twitching right eye-brow, pulse of 
high tension, viscera otherwise negative; reflexes normal; urine normal; 
red cells, 3,832,000; white cells, 10,000, with 76 per cent, polynuclears. 
By May 2d Kernig's sign, photophobia, and marked stiffness of the neck 
had developed. The patient moaned continuously, and had headache 
unless she was kept under morphin. 



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Fig. 9. — Chart of case 18. 

Discussion. — Any headache near the time of parturition naturally 
suggests uremia or some related autointoxication, but in this case nothing 
was found in the examination of the urine or of the heart to support these 
ideas. 

Cerebral hemorrhage or embolism is not uncommon near parturition, 
but would probably have a more sudden onset and produce paralysis 
or aphasia. 

Cerebral tumor should be considered and cannot be excluded with- 
out an examination of the fundus. The absence of focal symptoms 
and the presence of Kernig's sign, photophobia, and retracted head 
militate against it. 

Meningitis is left as the most plausible diagnosis, though the tem- 
perature-chart and the leukocyte count are against it. 



HEADACHE 7 1 

Outcome. — On lumbar puncture a clear fluid spurted eight inches 
through the cannula; immediate and great relief followed. The patient 
ceased moaning and went to sleep. A sediment of the fluid thus ob- 
tained showed very rare leukocytes or degenerate mononuclear cells 
and a few Gram-decolorizing bacteria not characteristic. Cultures 
remained sterile; urine, normal. After the lumbar puncture the 
pupils, which were previously inactive, became normal, the Kernig 
sign less marked, and the head, though still stiff, was not retracted. By 
the thirteenth of May there was marked improvement. The tempera- 
ture, as seen by the chart on p. 70, was entirely normal. Less mor- 
phin was required to control the headache. Consciousness returned 
on the ninth of May. May 13th she fed herself. 

May 19th : Marked improvement. Sits up daily. No stiffness of neck. 

May 28th: Red cells, 4,380,000; leukocytes, 4000; hemoglobin, 65 
per cent. . 

May 29th: The patient anxious to go home and is discharged. 

Just what type of meningitis was present could not be determined. 
At the present day an injection of Flexner's antimeningeal serum\would 
probably be indicated, despite the dubious results of this lumbar puncture. 

Diagnosis. — Meningitis. 

Case 19 

A married woman of thirty-five entered the hospital December 9, 
1897. She had septicemia after the birth of her baby, six years ago. 
She has never been quite as well since. For three weeks she has had a 
little cold in her head and a little headache, gradually getting worse, 
until four days ago, when she went to bed. Three days ago she began 
to have severe "neuralgic" headache, localized just above the left eye. 
She has had a hard, dry cough, which is now somewhat better; and for 
three days there has been some pain in the left chest on full inspiration. 

Physical examination showed the evidences of intense suffering from 
headache, marked tenderness at the exit of the left supra-orbital nerve, 
and less marked tenderness over its distribution. There is considerable 
voluntary spasm of the right rectus abdominis. The temperature 
is 100.5° F.J pulse, 90; respiration, 25; while cells, 74,000; urine, nor- 
mal. Freezing the supra-orbital nerve with ethyl chlorid gave no relief. 
Morphin in J-grain dose eased the pain, but soon after she became 
tic noisy, apprehensive, and almcsl delirious. She sat up in bed, 
trembling, breathing rapidly, with widely dilated pupils, said she could 
not get her breath, and wanted something to counteract the effect of the 
morphin. 



72 DIFFERENTIAL DIAGNOSIS 

Discussion. — The problems presented by this case are: 
i. Is the headache due to neuralgia, to frontal sinusitis, or to some 
other cause? 

2. What is the significance of the thoracic pain and of the abdominal 
spasm? 

3. What was the nature of the acute attack following the administra- 
tion of morphin? 

The fact that no relief was afforded by freezing the supra-orbital 
nerve argues against neuralgia. Sinusitis is made more likely by the 
direct sequence of the symptoms upon a cold in the head. There is 
nothing in the history to suggest any other diagnosis. 

Regarding the cause of the thoracic pain and the abdominal spasm, 
we must say, in the light of the outcome, "ignoramus." It should be 
said with emphasis that in almost every carefully studied case there are 
one or two facts like these which stray across the clinical field quite wild 
and untamed, and never submit to any rational explanation. If a case 
does not manifest some such symptom, but reels itself off like a text- 
book account, I always suspect that it is carelessly reported. 

At the time of the acute attack above described meningitis was sus- 
pected on account of the association of the mental symptoms and head- 
ache, but there was at no time any fever, and the results of treatment 
(see below) made it obvious that it was one of those semihysteric attacks 
of excitement which not infrequently follow the administration of mor- 
phin in idiosyncratic individuals. 

Outcome. — She was reassured in regard to her breathing, and 
given common salt in water to counteract the morphin, after which she 
was quiet for the rest of the night. The next morning the pain had al- 
most disappeared. The temperature was normal, and on the third day 
she was allowed to go home. 

Diagnosis. — Sinusitis. 

Case 20 

A farmer of thirty-five was seen October 8, 1906. About August 1st 
he began to have eruptions described as resembling giant urticaria in 
various parts of his body. He had previously been treated for an attack 
of angioneurotic edema. In the middle of August he had smothering 
sensations in his chest, which lasted from one to three hours. The 
coagulation time of his blood was then two minutes. 

Four and a half days ago he began to have headache, which has 
grown rapidly worse. Two days ago he had a chill at 3 p. m., and 
yesterday one at 7 P. M. Fever has been continuous since the onset. 



HEADACHE 



73 



The bowels have moved but once in three days. He has lost much 
money of late, but says he does not worry about it. 

Physical examination showed palpable glands in the neck, axillae, 
and groins. Examination of the chest and abdomen was negative. 
The blood showed no AYidal reaction. 

Discussion. — The questions which naturally present themselves in 
this case are: 

i. Can the headache and fever be due to some of the urticarial group 
of lesions, which, as we know, are sometimes associated with fever and 
sometimes manifest themselves in the internal organs (respiratory 
and gastro-intestinal tracts)? The smothering sensations complained 



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of in August may have indicated the involvement of the respiratory tract 
by lesions of the urticarial group. 

2. Can financial worry, owing to his money losses, account for his 
symptoms? 

3. What is the significance of the general glandular enlargement? 
leukemia? syphilis? 

In relation to the first question it must be said, first of all, that 
urticarial or erythemafc us almosl aever occur on mucous surfaces 

and serous membranes alone. If the fever and headache were of this 
type, there ought to be eternal lesion. 

Neither worry nor any other psychic event produces a fever like 
that here shown. 



74 DIFFERENTIAL DIAGNOSIS 

The text states that glands are palpable in the neck, axillce, and 
groins, but this is far from indicating that the glands are now in a dis- 
eased condition. Glands are palpable in health in a large majority 
of adults in one or more of the above-mentioned situations. Neverthe- 
less, the possibility of leukemia cannot thus be dismissed. I recently 
saw a leukemic case with signs much like those here described, and 
with a total leukocyte count nearly the same, the differential count, how- 
ever, showing 95 per cent, of lymphocytes. As a matter of fact, this 
examination was made in the case here under discussion, but the blood 
was wholly normal. 

General glandular enlargement certainly suggests syphilis, but such 
enlargement was not present in this case, the glands being no bigger 
than normal. There is nothing else in the case to suggest syphilis, 
though a fever of this type is quite compatible with syphilis. 

The suggestion of malaria (chills) was promptly negatived by the 
blood examination. 

The clinical picture then is that of a jever with nothing to show for 
it. This makes us suspect typhoid, especially in October. The absence 
of Widal reaction at this stage of the fever is, of course, not evidence 
against typhoid. Still the diagnosis is not certain. Is there any way of 
making it more certain? Blood culture should certainly be undertaken. 

Outcome. — A blood culture showed a bacillus giving all the reactions 
of the typhoid organism. White cells, 6000. The Widal reaction did 
not appear until the seventeenth. The course of the fever was unevent- 
ful. He was discharged well on the eighth of November. 

This case well illustrates the value of blood-cultures, which are most 
likely to be positive at the very time when the Widal reaction oftenest 
fails us, viz., at the beginning of the disease. 

For the treatment of this case see Appendix B. 

Diagnosis. — Typhoid. 

Case 21 

A sailor of twenty-seven entered the hospital November 26, 1906, 
He has lost one sister of " meningitis." Six months ago he had malaria, 
with chills every second day for three weeks. He has not felt perfectly 
well since. He denies venereal disease. Two weeks ago he began to 
have slight, throbbing headache, with blurring of eyes and general 
fatigue. Three days later he felt feverish. Eight days ago the head- 
ache became severe enough to confine him to bed, where he has been 
since. His appetite has been poor. Vomiting has been frequent. He 



HEADACHE 



75 



has lost much weight and strength. The course of the fever is seen in 
the accompanying chart (Fig. n). 

On physical examination the right pupil was found to be slightly 
larger than the left; both reacted normally; heart and lungs normal, 
except that respir ation at the left apex was rather hars h, with slight 
dulness. A rare sibilant rale was heard over this area. White cells, 
8300; polynuclear cells, 80 per cent.; there were no malarial parasites. 
Widal reaction negative, November 26th, 29th, and December 1st. 
The urine was normal; fundus oculi perfectly nor- 
mal; sputa negative; stools normal. 

Discussion. — Naturally, our first thought is of 
typhoid, but after ten days of fever the temperature 
should be higher in typhoid, unless, indeed, we are 
dealing with one of the rare abortive cases which 
finish themselves up within ten days, so that we are 
here seeing only the tail end of the disease. Against 
this, however, militates very strongly the total 
leukocyte count (almost always subnormal at this 
stage of typhoid), and especially the high percentage 
of polynuclear cells, which is practically unknown 
under these conditions. 

The history of a previous malaria makes that 
disease worth a moment's consideration, but as this 
individual has not been out of a temperate climate 
for many months, it is practically impossible that he 
should have acquired an estivo- autumnal malaria, 
which is the only type compatible with a fever-curve 
like that shown below. The patient's occupation brings syphilis to 
our minds as a possibility, but there is nothing else about the case to 
support this supposition. 

Brain tumor often produces a remarkably slow pulse, such as is seen 
in this case, but there is nothing else about the patient to verify this 
hypothesis. The fact that the patient is obviously sick and yet has a 
very slow pulse directs our attention still further to the possibility of a 
brain k->ion. Can he be suffering from tuberculous meningitis? There 
are no disturbances of the crania] nerves noi retraction of the head, and 
no leukocytosis, but the lung signs suggesl a possible tuberculosis there. 
Lumbar puncture should certainly It done unless further evidence soon 

appears 1o clear up the diagUO 

Outcome. — On the twenty-eighth slight stiffness of the neck on 
rd bending was noticed; otherwise there was no chai 




Fig. 11.— Chart of 
case 21. 



7 6 



DIFFERENTIAL DIAGNOSIS 



On the twenty-ninth he became slightly delirious, and in the evening 
required restraint and refused to swallow. 

On the first of December he became comatose, and the stiffness of 
his neck disappeared. On the third of December he died. Autopsy 
showed general miliary tuberculosis and tuberculosis of the mesenteric 
and retroperitoneal glands. 

Diagnosis. — Miliary tuberculosis. 

Case 22 

A bricklayer of sixty-four entered the hospital May 15, 1908. Three 
uncles upon his father's side died of consumption; his family history 
is otherwise good. He takes from a pint to a quart of whisky a day; 
has had gonorrhea many times; had chancre fourteen years ago, for which 
he was treated three years. He was down South at the time the present 
illness began, two weeks ago; he does not seem to 
know exactly how he got there. He has been in 
bed for a week and a half, complaining of nothing 
but headache and poor appetite. 

On examination, his pupils are equal, regular, 
and react normally. His temperature is as seen 
in the accompanying chart. His tongue is covered 
with a thick, dry coat. The heart-sounds are faint. 

I»"I~III A faint, systolic murmur is heard all over the pre- 
. Z IIIIIII cordia, transmitted into the axilla. The aortic 
second sound is slightly accentuated; heart not en- 
larged; the arteries palpable. In the lower half of 
the right lung, behind, slight dulness, diminished 
breathing, many medium and coarse crackling rales; 
abdomen and reflexes normal; white cells, 13,600; 
urine normal; Widal reaction negative. 

The patient was sent in with a diagnosis of 
typhoid fever, but showed at entrance only head- 
ache and bronchitis in an alcoholic subject. 
May 19th: The hospital record states that he does not need hospital 
treatment, and will be sent home in a day or two. 

May 21st: On the morning visit he seemed "dopey"; for the past 
two nights he has complained of severe headache. At n P. m. May 21st, 
he was found unconscious. 

Discussion. — The family history, the presence of lesions suggestive 
of a pleurisy at the base of the right lung, suggest the possibility of a 
tuberculosis with involvement of the meninges. This could only be 




Fig. 12. — Chart of 
case 22. 



HEADACHE 77 

partially excluded by lumbar puncture, and must remain a possibility 
in the diagnosis of this case. 

Headaches with nocturnal exacerbations suggest syphilis, especially 
in a patient who has certainly had that infection in previous years. It 
is impossible however, to go beyond suspicion unless we can get further 
evidence, such as disturbances of the cranial nerves, of the reflexes, a 
positive Wassermann reaction, or other syphilitic lesions. 

The history naturally suggests alcoholism ("wet brain"), but in the 
absence of any sign of delirium tremens this seems unlikely, since the 
amount of alcohol consumed in the last ten days has been almost nil. 

Typhoid and other infections disappeared from consideration when 
the temperature fell to normal and stayed there. 

Can the diagnosis be malaria? The patient has recently come from 
a malarial country, where he may have acquired a type of the infection 
not characterized by the familiar tertian or quotidian chills seen in tem- 
perate climates. In a case very similar to this, occurring in a drummer 
who had recently returned from a southern trip complaining of fever, 
headache, and prostration without chills, I found large numbers of 
estivo-autumnal "rings" in the red cells. The present case, however, 
showed no such evidences in the blood. 

It is much to be regretted that we made no measurement of blood- 
pressure in this case. An elevated pressure would support the sup- 
position that some brain lesion (tumor, hemorrhage, softening, or 
meningitis) existed. As it was, no diagnosis was made during life. 

Outcome. — In the evening the pupils ceased to react; the left arm 
and leg were cooler than the right; Babinski on both sides; abdominal 
reflexes absent; no paralysis made out. He died on the twenty-second. 

Autopsy showed subdural cerebral hemorrhage; hemorrhage into 
tegmentum of epencephalon; arteriosclerosis; atheromatous endocarditis 
of the aortic valve; fibrous endocarditis of the mitral valve; hypertrophy 
of the heart; syphilitic cirrhosis of liver; bronchopneumonia; acute 
fibrinous pleuritis; congenital cyst of kidney; round ulcer of stomach; 
fibrocalcareous tuberculosis of the lungs; chronic pleuritis; subcapsular 
hemorrhage of kidney. 

Diagnosis. — Cerebral hemorrhage. 



7» 



DIFFERENTIAL DIAGNOSIS 



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CHAPTER III 
LUMBAR PAIN 

Some years ago, when I was doing a good deal of work on the blood } 
I was asked to substitute as visiting physician to a convalescent home 
intended primarily for tired domestics and shop-girls. The matron 
met me with that patient and respectful expression which long service 
under many enthusiastic young physicians produces in some nurses. 
"I hear," she said, "that you are specially interested in the bloody 
Dr. R., the gynecologist, who was visiting last autumn, found that all the 
patients were gynecologic. When Dr. C. visits us in summer, he finds 
them all nose and throat cases — that's his specialty. Now that you are 
to visit us, I suppose they will all turn out to be blood cases" 

It must be explained that there was no election on the patients' part. 
They did not seek the institution because they heard that Dr. X. (a 
specialist in their particular trouble) was on duty. They were sent 
there by a variety of other physicians who had no knowledge of the 
interests of the different attending specialists. 

Now, in a similar way, we may explain, I think, the various interpre- 
tations of backache given by different physicians, each according to his 
point of view. To the gynecologist backaches are usually gynecologic 
symptoms; to the orthopedist, they result from sacro-iliac disease or 
postural strain; to the neurologist, they represent one phase of habit- 
pain due to a psychoneurotic make-up. There are stomach specialists 
who explain backache as a result of malnutrition, gastroptosis, or consti- 
pation (loaded colon). 

So it goes ! The one thing which remains unchanged is the backache. 
When we find 15 or 20 drugs recommended for one disease, we are in- 
clined to believe that none of them has much value. Similarly, when 
we find many and various explanations for one condition, it is natural 
to doubt whether any of them are true. 

The one thing clear about the obscure backaches called "functional," 
"postural," "uterine," "sacro-iliac," etc., is relief by mechanical com 
prcs icd about the pelvis and lower lumbar region by means oi 

corsets, plaster Strapping, belts, or olaster-of- Paris. 

In many ci^es a Strong neurotic element can be traced the mental 
or nervous V ■ < tin-/ on the beu I; through a reduction of muscular 

tone. Flabby mind, Babby muscles, unsupported joints, pain. Doubt 



80 DIFFERENTIAL DIAGNOSIS 

less any of these factors (and probably various others) may so "activate" 
the rest that in various ways the back may be made to ache. I do not 
think that any one knows much about it. 

On the gynecologic side the most careful study of backache (and 
other pains) in relation to pelvic disease is that reported by Dr. C. T. 
Dercum, 1 of Philadelphia, in which she shows statistically what I have 
long believed from unrecorded but fairly extensive observations in the 
Women's Medical Clinic of the Massachusetts General Hospital, viz., 
that there is no type of backache or other "reflex" pain which can 
reasonably be referred to pelvic disease. All types of pain in the back, 
head, and extremities occur with equal frequency with and without 
pelvic disease. All types of pelvic disease exist with and without back- 
ache. Even deep-seated cancerous growths may be latent and symptom- 
less for many months. 

The tables on page 83 from Dr. Dercum's article show to my satis- 
faction the mutual independence of backache and pelvic disease. 

Aside from this huge group of backaches cured by mechanical sup- 
port and lateral compression of the pelvis, but explained in many ways, 
as gynecologic, neurasthenic, or functional, as sacro-iliac strain or as 
loss of balance, 2 etc., we have two other affections which I have found 
it convenient to bracket with it under the clumsy title of the orthopedic 
group of backaches. These diseases are: 

1. Lumbago. 

2. Hypertrophic spondylitis. 

These may be for a time indistinguishable from each other and from 
the larger and vaguer group above referred to. 

The "kidney group" of causes for backache is a term which I shall 
use throughout this chapter to denote the "surgical" diseases in or near 
the kidney: tuberculosis, stone, neoplasm, abscess, cystic degeneration. 

The "pressure group" refers to diseases which involve a progressive 
compression of the lumbar cord or its nerves: aneurysm, neoplasm, 
vertebral tuberculosis. 

Some of the commonest causes of lumbar pain will not be discussed 
in any detail here. Probably more persons experience such discomfort 
as a result of — 

(a) Fatigue and simple weariness than from any other single cause. 
The patient usually finds this out when the pain goes off after a rest. 

1 The Nervous Disorders in Women Simulating Pelvic Disease; An Analysis of 591 
Cases, Jour. Amer. Med. Assoc., March 13, 1909, p. 848. 

2 Reynolds and Lovett, An Experimental Study of Certain Phases of Chronic Back- 
ache, Jour. Amer. Med. Assoc, March 26, 1910, p. 1033. 



Causes of Lumbar Pain 



1. FATIGUE AND DEFECTIVE BALANCE ("FUNCTIONAL ] 

BACK". 

2. CHILDBIRTH 

3. INFECTIOUS DISEASES 

4. POSTOPERATIVE 



CASES TOO MANY 
AND TOO VAGUELY 
ENUMERABLE FOR 
GRAPHIC REPRE- 
SENTATION. 



5. SACRO-ILIAC DISEASE) 

'NON-INFECTIOUS) / 

6. LUMBAGO 

7. HYPERTROPHIC) 

ARTHRITIS / 

8. HERPES ZOSTER | 

("SHINGLES") i 

9. INFECTIOUS ARTHRITIS \ 

OF SPINE J 

10. ACUTE SPRAIN OF THE) 

BACK i 

11. RENAL STONE 

12. SPINAL TUBERCULOSIS 

13. RENAL SUPPURATION 

14. PERINEPHRIC ABSCESS 

15. RENAL TUMOR 

16. CANCER OF THE SPINE 

17. RETROPERITONEAL) 

TUMOR / 



711 
549 
351 

214 

178 

149 

109 
72 
65 
26 
16 
6 



' 



PAW 83 

\BLE I. 

.fAL. 

70 14 

14 

■ ndernes*) 20 3 

:iframarnr: 2 

2 

1 o 

3 1 

in the doi j j 2 

M //?>- lumhnr reyiav. 4 

nMN 14 3 

IO 2 

ipu la 4 

3 

pain (hysti ■' 10 o 

mucous t^ina, vulva, rectum, and 

tongue 4 

thighs, am loulders) 40 3 

Sacral backache 10 

Lumhnr bat / -////•' .2 7 

Headai hes, verti< al ... 3 

6 2 

frontal and o< < ipital 3 

'-' < [pita! 5 

Headai hes, frontal , . . x6 3 

... 3 o 

r ic pain in one < ;.«■ during I 1 o 

ric" globus ', o 

Disturbed sleep iS 5 

I n so mn ia . 3 o 

Gastro-intestinal disturban< 1 is origin, su< h as< onstipa- 

tion, flaii. and ano- 

96 12 

TABLE 11. 

^ '<ther 

PaTHOLOOII CoMDnSOM. I enit 

- Bt 

Ion of the 1 ervii 3 o 

THibo-ovarian inflammations and exudati 

Fibroid growths, in. Lu< 1 ijj;liirij^ 17 pounds 

al and perineal la* 'rations 

Ann-lli i< 
When both 

P 





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1- 1 



84 DIFFERENTIAL DIAGNOSIS 

Sometimes, however, the fatigue has become cumulative, and is so 
chronic that it has developed, as it were, into a member of the household. 
Its source and origin may have been forgotten, and come to light only after 
close questioning or as a result' of a therapeutic test, viz., a thorough rest. 
In persons of high-strung, hypersensitive, and neurotic temperament, 
these simple fatigue pains merge into what may be called — 

(b) The psychoneurotic backaches, which have certain character- 
istics worth noting here. Pains of this type are often confined to the 
region of the coccyx, and, unfortunately, they are apt to lead the patient 
into the hands of some fervid and eager surgeon, who speedily does an 
operation on the coccyx. If the operation is followed by prolonged rest 
with hypernutrition and a considerable amount of reeducation given 
consciously or unconsciously by the surgeon or his assistant, the patient 
may recover, but the credit is falsely given to the operation, which would 
have been quite useless — as, indeed, it often proves — without the nutri- 
tive and educational influences linked to it. 

Another type of psychoneurotic backache makes the patient ab- 
normally conscious of the whole length of his vertebral column, which is 
affected, not only by pain, but by a variety of paresthesias, tingling, sen- 
sations of heat or cold, sensations of pressure or crawling. This type of 
trouble may arise without any obvious reason, hitf^j)^|^^ftM|met 
with following some accident, whence the term, "railway spme^^Bn the 
vast majority of these cases, however, the accident has served 1 ilfely 
to direct the patient's attention to a certain part of the body, in thiMase 
the spine, and also to perturb his moral consciousness through the ex- 
pectation of damages and court-room scenes. 

A third type of psychoneurotic backache, to which further reference 
will be made below, is recognizable by its obvious connection with 
psychic and especially emotional states. A depressing emotion will 
produce it, a joyful event will cure it; but one must beware of doing the 
patient injustice by dubbing the pain imaginary or unreal, either in this, 
or any other type of psychoneurotic trouble. What the facts show is 
that a certain direction and morbid concentration of attention is fol- 
lowed by pain, and that a new habit of life, physical and mental, leading 
to a more profitable direction of attention, is followed by relief. The 
most plausible hypothesis, and also the most useful one, because the 
most helpfully comprehensible to the patient, is that which assumes 
the following: Numberless physiologic changes are occurring every 
moment in every part of our anatomy — the circulation of blood, the 
distention and contraction of blood-vessels, the movements of lymph- 
currents, the varying tension and pressure of muscular masses, ligament- 



v/i 



LUMBAR PAIN 

ous strands and fasciae — all these and presumably many other phenom- 
ena go on very busily but quite unconsciously when our minds are normal ; 
but when attention gets caught and concentrated upon the spine or the 
coccyx or the back of the neck, and when the patient has made a mental 
picture of the organ which he supposes to be diseased (" the base of the 
brain," "the whole spinal cord," a the outlet of the stomach," "the 
left ovary"), then this unfortunate begins to be aware of physiologic 
processes normally unfelt. This very awareness, through the forma- 
tion of brain habits and possibly also through vasomotor influences 
acting upon the points supposed to be diseased, reinforces and increases 
the sensations referred to this point until they finally attain the dignity 
of pain, which ultimately becomes a habit ("habit pain"). 

I shall not try to exemplify in any detail this type of pain, though it 
is one of the most common in the practice of all busy physicians. 

(c) Lumbar pain due to parturition is only rarely mistaken for any 
other variety, and offers, as a rule, very little diagnostic difficulty. 
Obviously, it is one of the commonest of all such causes. 

(d) Backache from infectious disease of any type, from a simple 
cold to the severest septicemias and pneumonias, is, I suppose, the next 
commonest variety. Occasionally this type offers some difficulties in 
di^0Mi^fcB0HpiiA>f which will be considered later. In the great 
major^^Cf cases, however, the presence of fever, headache, and widely 
di^Kited pain in other parts of the body enables us to identify infec- 
tiousoackache without much difficulty. 

(e) Postoperative backache appears usually about twenty-four hours 
after the operation, and is troublesome for the next two or three days. 
Though often associated with gaseous distention of the lower bowel, 
there seems to me to be no good reason to believe that the distention 
causes the pain, since similar distention is so commonly present in 
typhoid, pneumonia, and other infectious diseases without any back- 
ache. The postoperative lumbar pain seems to be more common after 
prolonged operations in which the patient's back rests upon a flat table. 
so that the normal spinal curvature is no longer maintained by muscular 
tone, which the anesthetic relaxes. Pressure by the surgeon or his 

;iit upon the patient during operation may contribute to the 
result. If this explanation be correct, the backache should be prevented 
by padding or curving the surface of the table to correspond with the 
normal lumbar curve of the spine. 

The types of lumbar pain nexl to be d I all differ from those 

mentioned in two important listed so far have 

ir commoner than those -till to be mentioned, and Ear less depend- 



86 DIFFERENTIAL DIAGNOSIS 

ent upon direct physical examination for their recognition. It is for 
this latter reason that diagnostic difficulties are far commoner in the 
still remaining groups already mentioned on p. 80. 

(f) The Orthopedic Group. — What was almost universally called lum- 
bago ten years ago has now been split up into three main subtypes of 
disease: spinal osteo-arthritis, sacro-iliac disease (n on- tuberculous), 
and a residue still known under the name of lumbago. Despite the 
important differences which have now been demonstrated and have 
given rise to this separation, these three diseases are still loosely bound 
together by the fact that their treatment is very similar. It is, however, 
altogether for reasons of convenience in the discussion of differential 
diagnosis that I have linked them together under the title of the orthopedic 
group. They differ sharply, both in prognosis and treatment, from all 
the types of disease above referred to, as well as from those next to be 
described. 

(g) The pressure group of diseases causing lumbar pain includes 
vertebral tuberculosis (Pott's disease), aortic aneurysm, and neoplasm 
in or near the spinal column. I am quite aware that this term has no 
other merit than that of convenience for discussion, since in two members 
of the lumbago group pressure is also the cause of the pain. 

(h) The kidney group of causes for lumbar pain includes renal stone, 
tuberculosis, neoplasms, hematogenous infection of the kidney, and para- 
nephritic abscess as its chief members. Among the rarer causes for 
lumbar pain may also be mentioned renal infarct, hydronephrosis, 
pyonephrosis, and cystic kidney. 

(i) Lumbar neuralgia or neuritis, clearly recognizable only in the 
presence of the vesicular eruption (herpes zoster or shingles), is a com- 
paratively rare cause for lumbar pain. Of about equal rarity as a cause 
of such pain is — 

(;) Cholelithiasis. — Perhaps one case of gall-stones in a hundred shows 
itself by pain starting in the back and working toward the gall-bladder 
instead of in the opposite direction, as is usual. 

With lumbar pain or tenderness due to ulcer or cancer of the stomach 
or bowel I have had no experience, though I have asked and examined 
for such pain many times. Schmidt 1 mentions very specifically that in 
lead-poisoning sharp lumbar pain is occasionally associated with the 
ordinary abdominal colic. 

To investigate the cause of lumbar pain it is well to ask the follow- 
ing questions: 

1 Pain, Its Causation and Diagnostic Significance, by Rudolph Schmidt, translation 
published by Lippincott. 



LUMBAR PAIN 87 

(1) Is it unilateral (diseases of the renal group especially) or bilateral? 

(2) Is it of long duration? Chronic lumbar pain points especially 
to the psychoneuroses and to the pressure group of causes. 

(3) Is it made much worse by stooping or sidewise bending? This is 
the characteristic of the lumbago group and of many psychoneurotic 
cases, while diseases of the pressure group and the kidney group are not 
thus characterized. 

(4) Is the lumbar region sensitive to pressure or percussion? Such 
sensitiveness is especially common in diseases of the renal group, but if 
localized over the sacro-iliac joint, it often points to disease there. 

(5) Does pain radiate along the course of the intercostal nerve? 
This occurs especially in the lumbago group and the pressure group. 

(6) Does the urine contain blood or pus? 

EXAMINATION OF PATIENTS WITH LUMBAR PAIN 

Incredible though it seems, there are physicians in practice to-day 
who do not hesitate to treat lumbar pain without stripping the patient 
so that the naked back can be examined. I have known a case of 
herpes zoster to be treated for u rheumatism " (salicylates, alkalis, m 
vegetable diet, etc.) simply because the vesicular eruption was unknown 
to the patient and had never been looked for by the physician. 

Osier mentions a case of aneurysm of the descending thoracic aorta, 
which presented as a pulsating tumor near the angle of the left scapula, 
quite undiagnosed through many weeks of treatment for lumbago and 
neuralgia. The attending physician had never examined the exposed 
back, presumably because the patient, being a male, wore clothes which 
opened in front and did not offer to remove them. 

Once we have formed the habit of examining the naked back, we 
should note especially: 

(a) Is the spine rigid locally or throughout ? (Allowance must be 
made for the moderate rigidity of normal old age.) 

(b) Is there any tenderness over the spinous processes? 

(c) Is there any dulness on percussion of the bases of the lungs? 
(Renal abscess or neoplasm may push up the diaphragm and encroach 
upon the thoracic space.) 

(d) Does the patient stand or walk with a list to one side? 

(e) Has he any fever? 

Case 23 

A Swedish tinsmith, twenty years of age, of exceUenl hmily hist 
oast history, and habits, entered the hospital on the twenty-fifth of June, 



88 DIFFERENTIAL DIAGNOSIS 

1908. On June 7th, while sitting in a chair upon his piazza, he had a 
sudden attack of sharp pain in the right lower back. This pain con- 
tinued severe for the next six days, and on the day after its onset he began 
to be short of breath on slight exertion. A dry cough began at the same 
time, and has persisted since. His appetite has been poor, but he has 
not been in bed. He has had no constipation or other symptoms. 

When first seen, his temperature, pulse, and respiration were normal. 
His heart's apex was i\ inches to the left of the nipple-line in the fifth 
space, the right border of cardiac dulness two inches to the left of the 
midsternum line in the fourth space. The heart-sounds were of good 
quality, and there were no murmurs. The upper part of the right chest 
was slightly dull as low as the third rib. Below this there was tympany 
extending two inches to the left of the midsternal line, below the costal 
margin, and to the middle of the right axilla. Tactile fremitus was 
diminished over this area, and breath-sounds distant or altogether 
absent, except at the right apex, where the voice sounds were increased 
and the breathing was bronchovesicular. 

In the back, with the patient sitting up, there was relative dulness 
down to a point ij inches below the angle of the scapula, the line of 
resonance rising from that point obliquely across the axilla to the level 
of the third rib in front. Below this there was tympany. 

Over the dull area in the back fremitus is diminished, and at the 
extreme base absent. Otherwise the signs are the same as in the corre- 
sponding area in the front. There are no rales, no friction or other ab- 
normal sounds. 

Physical examination is in other respects negative. The blood and 
urine are normal. 

Discussion. — As we read the signs set down in this case, pneumo- 
thorax is naturally our first thought. But can pneumothorax occur so 
suddenly in a person of excellent health and without any of the known 
causes of pneumothorax (phthisis, trauma)? Let us consider the other 
possibilities before answering this question. 

Pain, dyspnea, and cough suggest pneumonia, but the absence of 
fever and of any evidence that the patient has had and passed a crisis 
exclude this. 

A sharp thoracic pain, followed by dyspnea and cough, constitutes 
the ordinary onset of pleurisy, but the physical signs of this case, especially 
the tympany at the base of the chest, together with the absence of the 
friction sounds, exclude this. 

Passing to other possible explanations of the tympanitic resonance 
just referred to, we think of emphysema; but this cannot be so localized, 



LUMBAR PAIN 89 

and is never of sudden onset. The presence of gas below the diaphragm, 
either in the bowel or in an abscess cavity, would explain many of the 
signs in this case; but there is no history of any previous abdominal 
symptoms, such as usually lead to the so-called subphrenic pyopneumo- 
thorax. There has been nothing to suggest appendicitis, perforating 
gastric ulcer, or hepatic abscess. There are not enough fever and con- 
stitutional disturbance. 

We, therefore, return to the first supposition, viz., pneumothorax. 
Investigation of any large number of cases of this disease shows that 
mptoms may be either stormy and virulent, or so mild as to be prac- 
tically negligible. Twice I have seen pneumothorax (proved to be such 
by the liberation of air through puncture) in patients who felt practically 
well and were examined almost by chance. This means that the cause 
present and leading to the vast majority of all cases of pneumothorax — 
namely, tuberculosis — may be absolutely latent and symptomless. 
This is, of course, a well-known fact, but the sudden appearance of a 
tuberculous pneumothorax brings the truth home to us in a startling 
way. 

Outcome. — The patient was given 3 milligrams of tuberculin after 
five days of normal temperature, and the temperature thereafter rose to 
101 F. and was accompanied by headache and malaise. 

The patient was accordingly transferred to a sanatorium for tuber- 
culosis. 

The prognosis in a case of this kind and the treatment are those of 
the underlying process — phthisis. The advent of pneumothorax does 
not render the outlook much graver. In the great majority of cases the 
air is readily absorbed, and no special treatment need be directed to it. 
If the air persists in the chest unchanged for a number of weeks, or if 
its amount is so large as seriously to embarrass the action of the heart 
and lungs, it may be removed by puncture, after which it may, or may 
not, reaccumulate. 

Diagnosis. — Tubercular pneumothorax. 

Case 24 

A stationary fireman of fifty entered the hospital November 9, igoi. 
years ago, following an injury to his left elbow, the joint gradually 
grew stiffer, and he was told that there was a growth of bone there-, 
.me to the outpatient department for treatment, and the elbow- 
was baked daily for five weeks, with considerable benefit, but he has 
r been able full}' to extend the arm sinee that time. 

Thn n to have shooting pains across the small 



90 DIFFERENTIAL DIAGNOSIS 

of his back, brought on by any motion. Three days ago these pains 
became so severe that he could scarcely move. The pain now starts 
in the small of the back and extends down the left leg as far as the ankle. 
Three days in bed has given him no relief. 

Physical examination showed well-marked Heberden's nodes on the 
fingers. The physical examination was otherwise negative, except that 
the left elbow could not be flexed beyond 80 degrees or extended beyond 
45 degrees. There was tenderness along the back of the left thigh from 
the popliteal space to the sacrum, also over the Achilles tendon, pressure 
on which causes pain to shoot up the thigh. 

So long as the patient remained absolutely quiet he was comfortable, 
but coughing, sneezing, any movement of the leg or body caused pain to 
shoot from the sacrum to the foot. Fixation with a ham splint afforded 
no relief, nor did the application of co]d along the nerve. Drugs were 
without effect. Heat, on the other hand, relieved him somewhat. 
Tight criss-cross strapping of the lower back and, later, a supporting 
belt, gave' still more relief, although numbness of the thigh and calf 
developed as the pain diminished. 

Discussion. — The great majority of cases of pain in the back fall 
into three groups: 

1. The infectious group. 

2. The orthopedic group. 

3. The renal group. 

The first and the last of these may be excluded by the absence of 
fever and of urinary signs. Within the group which I have called ortho- 
pedic fall chiefly lumbago, sacro-iliac strains and displacements, spinal 
osteo-arthritis. 

Lumbago is pretty definitely excluded by the long duration of the 
disease. After three weeks of pain we must find some other cause, 
especially as the pain is no longer confined to the lumbar muscles, but 
extends down the left leg. 

Sacro-iliac disease (strain, sprain, displacement, or pinching of joint 
fringes) should cause the patient to stand with a list to one side, and 
should produce tenderness over the sacro-iliac joint, together with pain 
increased when the leg is raised without bending the knee. Direct 
physical examination of the sacro-iliac joint usually reveals nothing in 
these cases except localized tenderness. In this case the above tests were 
all negative. 

Spinal osteo-arthritis is favored by the age of the patient, and by 
the presence of similar joint outgrowths elsewhere (elbow and fingers) 
Pain on coughing and sneezing is also rather characteristic of osteo- 



LUMBAR PAIN 9 1 

arthritic processes, because they so often involve the costovertebral 
joints, which have to move sharply and suddenly when we cough or 
sneeze. This symptom, however, also occurs in all the orthopedic 
group of diseases above referred to. 

Malignant growths in or near the spinal column might account for 
all the symptoms here present, and can only be excluded by x-ray 
examination or by the outcome of the case. 

Outcome. — X-ray showed osteo-arthritic outgrowths in the lower 
lumbar region. By December 5th he was able to walk about with 
crutches, and by the eleventh he was able to go home very much relieved. 

Diagnosis. — Hypertrophic spinal arthritis. 

Case 25- 

A motorman of twenty- four entered the hospital August 19, 1907. 
His habits and previous history were good, but for the past two weeks 
he has had pain across the small of his back. For the past four days 
the pain across the small of his back has become more severe and he has 
been nauseated when he tried to eat, although he has felt hungry. 

Six days ago he felt chilly in the evening and shivered a little; but he 
did not give up his work until two days before his entrance to the hospi- 
tal. This morning he had a brief spell of tingling in the left arm. He 
continues to feel hungry, but cannot eat. He does not feel at all weak. 
His bowels move once daily. 

At entrance the patient's temperature was 103. 8° F.; pulse, 88; 
respiration, 24. He was mentally alert, and did not look very sick. 
There was a harsh, systolic murmur heard all over the precordia, loudest 
in the pulmonary area, where there is a suggestion of a systolic thrill. 
The pulmonary second sound was slightly greater than in the aortic. 
The heart shows no evidence of enlargement. A slightly tender mass 
was felt to descend below the left costal margin on full inspiration. 

Physical examination was otherwise negative. The urine was normal. 
The Widal reaction was negative; the white cells ..ere 5400. 

Discussion. — The presence of continued fever excludes most of the 
so-called orthopedic group discussed in the last ease. We have left 
the infections, local and general. Local infections producing pain in the 
back are chiefly spinal tuberculosis, hematogenous renal infection, and 
perinephric al d luded in the present case, because 

the spine, the region of the kidney, anteriorly and posteriorly, and the 
urine, are all negative. We are left with the question, What general 
dons are most apt to cause backache? The answer is: "■ 
[litis, typhoid, and Of tonsillitis and sepsis we have no 



9 2 



DIFFERENTIAL DIAGNOSIS 



positive evidence, though the harsh systolic murmur mentioned in the 
text might suggest a sepsis of the type known as ulcerative endocarditis. 
There is, however, nothing conclusive about this murmur as described, 
and nothing else in the case to support the diagnosis of sepsis. The 
murmurs most suggestive of a septic endocarditis are those that rap- 
idly change their characteristics under observation, especially diastolic 
murmurs. 

The good appetite and the mental alertness are not characteristic 
of typhoid, but there is nothing in the case absolutely inconsistent with 
that diagnosis. The tender mass felt below the left ribs might be the 



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spleen. The absence of a Widal reaction is not unusual at the onset of a 
typhoid. 

In the absence of a well-marked infection of the upper air-passages 
with the influenza bacillus predominating in the discharges there is 
never any good reason for the diagnosis "grip." Such a diagnosis is 
usually a rather equivocal way of saying "I don't know." The word is 
used largely to satisfy the patient. 

On the evidence thus far presented, then, one can only guess at the 
diagnosis of this case. Only as the chart develops do we begin to feel 
any more confidence that our original guess, typhoid, is correct. 

For treatment see Appendix. 

Outcome. — The subsequent course of the temperature is shown 



LUMBAR PAIN 93 

in the accompanying chart. The Widal did not appear until August 
25th. The mind was clear and alert throughout, and after the twenty- 
eighth the mass was no longer felt in the left hypochondrium. The 
patient sat up on the twenty-second of September, and went home well 
on the first of October. 
Diagnosis. — Typhoid. 

Case 26 

A widow of fifty entered the hospital March 17, 1908. Her history 
was always negative up to a month previously, when she began to have 
pain in her lower back and in her right hip, making it difficult to lie down. 
The pain was sharp, constant, and increased by motion. It was usually 
relieved by heat, but last night she had to take morphin to get to sleep. 
She has worked until four days ago, though her appetite has been poor, 
and she has some nausea and loss of weight. 

On the right back, on a line with the spine of the ilium, is a group of 
broken vesicles covering an area of 2\ inches by one inch, and extending 
at right angles to the spinal column. Temperature, pulse, and respira- 
tion normal. 

Dr. R. B. Osgood found nothing wrong in the bones and joints. 
Vaginal examination was negative, as were the blood and the urine. 
Dr. James J. Putnam considered the pain due to herpes. She slept well 
on the night of the twenty-first after 10 grains of veronal, and aspirin in 
doses of 10 grains also relieved her. Acetanilid 5 grains with 2 grains of 
caffein was later given to insure sleep. Aconitin in ^ to j-J-q- grain 
doses had no effect, although it was pushed up to the point of toxic 
symptoms, when she remarked that it made her feel cold and clammy, 
like a chicken just taken off the ice. Later her pain became more severe, 
and was not relieved either by aspirin, by quinin, or by strychnin. Phe- 
nacetin and salol relieved her more, and by the sixteenth of April she 
was able to sleep without any drugs at night. Veronal and codein, the 
former 10 grains, the latter half a grain, were repeatedly needed before 
April 10th for sleep. 

After she had been in the ward five weeks with normal temperature 
and pulse throughout, her temperature suddenly rose to IO3.5 F., and 
her leukocytes, which had previously been normal, rose to 10,200. 

The lungs were negative, but there was marked tenderness in the 

right lower abdomen, without spasm. The patient was so hypersensitive 

when she was touched at any point that it was difficult to know how 
i weight to lay upon her abdominal pain. 

By the twenty fifth the temperature had again reached normal; the 



94 DIFFERENTIAL DIAGNOSIS 

white cells were still above 15,000, and there was indefinite sensitive- 
ness in the right lower quadrant. 

On the twenty-ninth, after she had been sitting up, she appeared 
to be very sensitive in the right iliac fossa. 

Discussion. — Lumbar pain without fever and without evidence of 
any disease of the orthopedic group or of the kidney group should 
always suggest the possibility of a neuritis. The group of vesicles, 
though covering so limited an area, gives strong support to the hypothesis. 
Neuritis of the thoracic region, involving, presumably, in every case a 
lesion of the spinal ganglion corresponding, is especially apt to be 
accompanied by that vesicular eruption which we call herpes zoster or 
"shingles." In the majority of cases the painful area is much larger 
that the vesiculated area. It need not surprise us, then, that in this case 
the vesicles cover such a small spot, and we have no good reason to 
hesitate regarding the diagnosis— herpes zoster. Presumably this is 
due to a local infection of the spinal ganglion similar to that which has 
been demonstrated in the ganglia corresponding to the facial herpes in 
pneumonia. 

Regarding the treatment of this painful affection, it is worth noting 
that the application of an ethyl chlorid spray over the corresponding 
spinal ganglion sometimes gives very striking relief to the pain. 

Can the abdominal pain, occurring in the sixth week of this case, be 
attributed to a second attack of the same trouble? Experience has 
taught us never to multiply causes or diagnoses if the facts can be ex- 
plained otherwise. But in this case the occurrence of fever and leuko- 
cytosis, with the new pain, should make us look for some local in- 
flammatory cause. We should search for evidence of a local abscess, 
of tonsillitis, of phlebitis, arthritis, or pneumonia. By the twenty-ninth, 
when tenderness in the right iliac fossa was marked, there seemed to be 
every reason to suspect the appendix. 

Outcome. — On the second of May the white cells had risen to 31,000, 
and a distinct mass could be felt in the right iliac region. 

On May 3d the abdomen was opened and an ounce of pus evacuated 
from the region of the appendix. 

The patient's recovery was complete. 

This case constitutes one of those exceptions which prove the rule — 
the rule, namely, that we do not often deal with two diseases as the 
explanation for a group of symptoms. In the light of the findings at 
operations wc naturally ask ourselves whether the whole thing, from start 
to finish, might not have been due to appendicitis. I should answer 
decidedly, "No." The location of the original pain, the absence of 



LUMBAR PAIN 95 

fever, and the presence of the vesicular eruption seem to me to make 
this supposition impossible, though it is conceivable that there may have 
been a common cause both for the zoster and the subsequent appendi- 
citis. 

Diagnosis. — Appendicitis; herpes zoster. 

Case 27 

A married woman of twenty-one had "grip" three times last winter, 
but has otherwise been well until two w T eeks ago, when, after her last 
attack of "grip," she began to have pain in her back, and to a less extent 
in her arms, chest, and knees, without any limitation to the movement 
of the joints. For the past week she has been in bed, but for the past 
two nights she has slept little on account of pain in the back. 

When the patient was first seen, March 26, 1908, her temperature was 
101 F., pulse, no, and respiration, 25. 

The temperature remained elevated for four days; after that it was, 
for the most part, normal. The action of the heart was regular and rapid, 
with a gallop rhythm. The pulmonic second sound was accentuated, 
and the first sound at the apex was accompanied by a rough systolic 
murmur heard all over the precordia and in the axilla. There was no 
obvious enlargement of the organ. Physical examination was otherwise 
negative, except that the white cells numbered 16,300. 

Rest in bed, 10 grains of salicylate of strontium every four hours, with 
an ice-bag over the precordia, an occasional A. S. and B. pill, and an 
occasional | grain of morphin, gave her relief within a few days. Later, 
she complained of piercing pains in the precordia, which made her very 
nervous. Nothing was found there on physical examination. 

Discussion. — I have included this case because it seems best that 
my book should mirror some of the most annoying defects of our present 
knowledge, as well as its strong points. This is the sort of case which 
is ordinarily called "grip" at the start, while we watch for developments. 
If none come, the diagnosis is formally confirmed. 

For what other possibilities should we be on the watch in a case of 
this kind? Endocarditis, first of all, on account of the cardiac murmur, 
the leukocytosis, and the early joint pains. Only the disappearance of 
these symptoms with the lapse of a few days excludes endocarditis. 

Typhoid is made practically impossible by the presence of well- 
marked leukocytosis. 

As 1 have already said in the discussion of previous cases, 1 think 
"unknown infection" should be our verdict. It is time to drop the 
equivocal use of the word "grip" as a cloak for our ignorance. 



96 DIFFERENTIAL DIAGNOSIS 

It is worth noting that the use of an ice-bag over the precordia very 
probably accounted for a good deal of the patient's later suffering. It 
drew her attention to the possibility of heart trouble. In a nervous 
person this is enough to produce heart pains. 

Outcome. — Nervousness was throughout a prominent feature, but 
by the sixteenth of April she was nearly well, and was discharged to 
finish her convalescence at home. 

Diagnosis. — Unknown infection. 

Case 28 

A night watchman of sixty-nine entered the hospital January 31, 
1907, complaining that when he got up two days before he "felt his hip 
catch." Within three hours he was unable to bear any weight on the 
left foot and went back to bed. The pain has continued since, and he 
has been helpless. 

On physical examination it was found that any motion of the left 
hip or back caused exquisite pain. There was some tenderness at the 
upper point of exit of the nerve. Physical examination otherwise nega- 
tive. Temperature oscillated between 98 ° and 101.4 F. for four days, 
then normal. Whites, 8000. 

Flexion of the thigh, with the knee kept straight, caused pain referred 
to the left sacro-iliac joint. 

Discussion. — Can the symptoms be due to strain of the back? 
What tests should be employed to confirm or exclude the diagnosis of 
lumbago, of sacro-iliac disease, of hip disease, of spinal osteo-arthritis? 
What further data are necessary? 

In answer to these questions I should say that it is wholly unlikely 
that strain entered into the causation of these symptoms, since the pain 
was first felt after the blameless action of getting out of bed. 

For lumbago the main tests are for the production of pain by any use 
of the lumbar muscles, together with the absence of any disease of the 
bone or kidney. 

In relation to sacro-iliac disease we should endeavor to ascertain 
whether the patient stands with a list to the other side, whether the 
pain and tenderness are referred especially to the sacro-iliac joint when 
the thigh is flexed with the knee straight, whether there is any sacro-iliac 
pain on compressing the wings of the ilium. 

The therapeutic test, the effect of attempting to immobilize the 
joint by strapping or otherwise, is also of importance. Hip-joint 
disease is to be excluded in case the motions at that joint are really 
free. 



LUMBAR PAIX 



97 



Osteo-arthritis is difficult to exclude or to identify positively. We 
suspect it in the presence of long-standing lumbar pain associated with 
radiations along the thoracic, lumbar, and sciatic nerves, aggravated 
if when the muscular protection is relaxed in sleep, the patient at- 
tempts to turn over. It is aggravated also by coughing and sneezing. 
An .v-ray picture and the exclusion of sacro-iliac disease complete our 
task. 

The present case offers a fairly characteristic picture of what is 
ordinarily known as sacro-iliac sprain or strain. The pathology of this 
affection is still very obscure. It may be that one of the joint fringes 
gets pinched owing to slight relaxation or subluxation of the joint when 
the muscular or ligamentous protection is imperfect. A person becomes 
debilitated or tired, muscularly or nervously. His muscles are no 
longer as alert and well toned for protection as they should be. A slight 
slip occurs, and a joint fringe or some other sensitive joint structure is 
impinged upon. If this were true, it would explain the frequent asso- 
ciation of the trouble with neurasthenic and debilitated states. 

Outcome. — The patient was considerably relieved by 10 grains of 
aspirin every four hours and tight cross-strapping of the back and hip. 
He was able to leave the hospital by the twenty-fifth of February. 

Diagnosis. — Sacro-iliac strain. 

Case 29 

A nurse of thirty-six who had previously suffered from dysentery 
when nursing in the Philippines, entered the hospital March 21, 1908, 
complaining that for the past four months she had had pain in the lower 
part of her back, extending down the right leg. She has also had swelling 
of the right foot and stiffness of the neck off and on during these four 
months. The pain is somewhat relieved by heat, but she has had to 
have morphin pretty continuously in order to keep her comfortable. 

She has been unable to work since the previous December, and has 
lost 20 pounds in the past five weeks. 

On physical examination the thyroid gland was found to be slightly 
enlarged. Temperature, pulse, and respiration were normal, the chest 
and abdomen negative. Trine normal. 

The pulsations of the aorta were violent in the epigastrium. The 
knee-jerks were extremely lively, but there was no clonus and no Babin- 
ski. Cr068-Strapping gave her a great deal of relief. 

Discussion. — Here is a long-standing pain which, in a woman of 
thirty-six, should make us consider Pott's disease and cancer; but ex- 
amination shows no evidence of either of these troubles, and a closer 



9 8 



DIFFERENTIAL DIAGNOSIS 



study of the case shows two causes whereby the duration of the pain may 
well have been inordinately prolonged. I refer to the use of morphin 
and to the evidence of a hypersensitive temperament, shown in the 
exaggerated knee-jerks and the violent pulsation of the abdominal aorta. 
Coming then to the milder possibilities, we should naturally think of 
lumbago, because the patient has also suffered from stiff neck (so often 
associated with lumbago). The duration, however, is somewhat too 
great. She should have been relieved by rest within a week or two. 

The pain extends down the right leg, and is accompanied by swelling 
of the right foot. Can it be due to neuritis? There were no nerve 
tenderness and no disturbance of sensation. The ordinary tests for 
sacro-iliac disease (see above) were positive. 

Outcome. — Dr. Goldthwait saw the case in consultation and made 
a diagnosis of chronic strain in the right sacro-iliac joint. 

Diagnosis. — Sacro-iliac strain. 



Case 30 

A school-girl, eight years of age, entered the hospital May 26, 1908, 
complaining of dull, constant pain in the right side of the lower back, 

worse at night, accompanied by 
fever, vomiting, and constipation. 
Her bowels have not moved for four 
days. There has been no injury to 
the back, no cough, and no chill. 
Family history and previous history 
are negative. 

Physical examination showed a 
herpes on the lips. Nothing ab- 
normal was found in the chest or 
abdomen except for a general ten- 
derness, especially marked in the 
costovertebral angles and in the 
flanks. 

The urine showed a large amount 
of pus, and the culture revealed a 
characteristic growth of colon bacilli. 
The temperature remained above 
101 ° F. for a week. (See accom- 
panying chart.) The patient was at first very sick, with a white count 
of 24,000, 82 per cent, of the cells being polynuclear. 

Any lumbar pain with fever in a small girl suggests Pott's disease. 




Fig. 14. — Chart of case 30. 



LUMBAR PAIN 99 

This being excluded by the absence of any kyphos or muscular spasm 
about the spine, we have next to note that the patient is rather young 
for any of the orthopedic group of diseases. 

If it is an infection, as the fever suggests, is it local — that is, renal or 
perirenal — or is it general? The condition of the urine and the leuko- 
cytosis point strongly to a local urinary infection. 

Outcome. — The leukocyte count fell to normal along with the tem- 
perature. The treatment consisted of alcohol sponges at 8o° F. every 
four hours; urotropin, 4 grains, three times a day, an abundance of 
water to drink, and a liquid diet. 

By the eleventh of June the urine was nearly normal and the child 
practically well. 

In view of the rapidly favorable outcome in this case there was no 
need for any attempt further to verify the diagnosis by cystoscopy or 
ureteral catheterization. 

The renal infections, among which the hematogenous are not always 
to be distinguished from the ascending affections, may be subdivided into 
the following four groups: 

1. Those presenting in girl babies or young girls an apparently 
unaccountable fever, without anything to suggest its source. It is not 
always easy in these cases to collect and examine the urine, hence this 
most important clue is often neglected. The presence of a moderate 
or considerable number of leukocytes in the sediment of such a urine, 
when vaginal contamination is excluded, strongly suggests a urinary 
infection. A pure culture of colon bacilli can usually be obtained from 
the urine, as it was in this case, and the therapeutic test (rapid improve- 
ment under forced water-drinking and urotropin) puts the diagnosis 
upon a fairly firm foundation. 

2. In other persons the disease often sets in in an acute and threat- 
ening way, like appendicitis or acute cholecystitis. Fever, leukocytosis, 
pus in the urine, and tenderness in the costovertebral angle are a very 
suggestive group of symptoms and demand cystoscopy as confirmation. 
Nephrotomy or nephrectomy may be necessary to save life if the symp- 
toms do not rapidly abate after the ingestion of urotropin and large 
amounts of water. 

3. Relatively mild and chronic cases, characterized by pyuria, with 
waves of irregular fever and possibly some bladder symptoms, often 
occur in women before or after parturition. In some of those chronic 

the urotropin and water treatment may be assisted by the use of 
I ine prepared from the organism isolated from the urine — almost 
ys the colon bacillus. 



IOO 



DIFFERENTIAL DIAGNOSIS 



4. There seems to me to be good reason to believe that most, if not 
aU, cases of perinephric abscess represent neglected forms of the hema- 
togenous infections just classified. It is a notable fact that in the past 
two years, since our attention was called to the frequency of hematogen- 
ous renal infections by the papers of Brewer and Cobb, the number of 
cases of perinephric abscess has greatly diminished. 

In my opinion there is no longer any ground for supposing that a 
primary pyelitis, distinct from ascending infections, exists at all. It has 
neither a pathologic nor a clinical basis. 

Diagnosis. — Renal infection, hematogenous or ascending. 

Case 31 

A waitress of twenty-six, of good family history and previous history, 
entered the hospital January 30, 1908. Up to yesterday morning she 
had been well. She then was seized with pain in the right lumbar 

region and lower back. This pain 
has persisted and become worse ever 
since. She has vomited a clear liquid 
several times, and has had some 
cough, with thick white sputum. She 
has no abdominal pain, but consider- 
able headache. 

Physical ' examination showed 
many papules scattered over the en- 
tire body. The conjunctivae were 
injected and watery; the breath offen- 
sive. At the angle of the right scapula 
the respiration was slightly dimin- 
ished, and the whisper slightly in- 
creased. The right kidney was 
doubtfully felt, and there was some 
tenderness there, but more marked 
tenderness under the right costal 
border and in the right iliac fossa. 
The general abdominal tenderness was so marked that the patient 
was seen by a surgical consultant who, however, found no evidence of 
peritonitis. The urine was negative. 

The temperature ranged for seven days above 101 F. (see accom- 
panying chart), and the white count between 13,000 and 15,000. The 
chest was strapped, with very slight relief. 

Discussion. — An acute lumbar pain, accompanied by fever, head- 



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LUMBAR PAIN IOI 

dche, leukocytosis, cough and some tenderness about the right kidney, 
suggests several possibilities. 

i. Since the pain began upon the right and is accompanied by some 
tenderness in the region of the right kidney, a renal infection must be 
considered, especially as the right kidney is far more often affected than 
the left by such infections. But in the presence of a negative urine all 
the other possibilities must first be carefully canvassed before proceeding 
to cystoscopy or any such bothersome tests. 

2. The orthopedic group of troubles seems unlikely in view of the 
acute febrile onset and the absence of confirmatory tests. 

3. Against the diagnosis of local peritonitis (gall-bladder, appendix, 
perf orating gastric ulcer) is the entire absence of muscular spasm and 
the very wide area of tenderness. 

4. Despite the exclusion of all these possibilities, the diagnosis re- 
mained uncertain. The rather doubtful signs at the base of the right 
lung were sufficient, however, to make us examine this part very fre- 
quently in anticipation of the possible development of pneumonia. So 
many cases beginning with abdominal symptoms have ultimately turned 
out to be pneumonia, escaping laparotomy narrowly, if at all, that we are 
always on the watch for such an event. 

Outcome. — On February 2d the signs of solidification finally ap- 
peared at the right base. Abdominal distention and tenderness were 
marked. The patient had a crisis on the evening of the sixth of Feb- - » s 
ruary, and by the fourteenth was out of bed and convalescent, though 
loud pleural friction, entirely unaccompanied by pain, persisted from 
the eleventh of February until her discharge from the hospital on the 
sixteenth. 

It is a familiar and a puzzling experience that many infections, 
especially pneumonia, cholecystitis, and appendicitis, begin with vague 
general symptoms (fever, wide-spread pains, chills, vomiting) before 
settling down to business in any discoverable locality. Looking back- 
over the course of such a chain of events, after the pneumonia or the 
appendicitis has been found, we are apt to suppose that the local trouble 
was really there all the time. The weight of evidence, however, seems 
to me to point the other way. The local manifestation of an infection is 
often, T believe, a late event in fact, as well as in our diagnoses. 

Diagnosis.- Pneumonia. 

Case 32 

A married woman of thirty entered the hospital October 27, [899. 

I ;r and a half years ago she bad had a miscarriage, induced by the 



102 



DIFFERENTIAL DIAGNOSIS 



introduction of a sound into the uterus, and a second miscarriage, with- 
out known cause, four years ago. Otherwise than this she had been 
always well until seven weeks ago, when she was taken with severe pain 
in the small of the back, which has lasted ever since, and which extends 
at times to the front of the abdomen. Her bowels are very costive, 
moving about once in five days. The pain in her back is not affected 
by motion, but has been severe enough to confine her to bed for the first 
two weeks of her sickness. Since that time she has been up part of 
each day, but has gained very little in strength, and has lost 20 pounds 
in weight. The range of temperature and pulse are seen in the accom- 
panying chart. The right lobe of the 
thyroid gland is palpable, and seems 
about the size of a plum. The patient 
has noticed this lump for several months, 
and says that it varies greatly in size, at 
times being scarcely palpable. 

The chest shows nothing abnormal. 
The abdomen shows slight general 
resistance and considerable general 
tenderness, the latter most marked in 
the left iliac fossa. Motions of the back 
are limited in all directions by muscular 
spasm, and seem to cause pain, es- 
pecially when she bends to the right. 
Pelvic organs normal. 

Examination of the stomach through 

a tube shows a capacity of only 16 

ounces. The position of the organ 

after distention with air was apparently 

normal. After a test-meal the stomach-contents showed 0.1 per cent. 

of free HC1, no lactic acid, and no blood. 

In the course of two weeks all the pains disappeared. Dr. Gold- 
thwait found no lesion of the spine, hip, or pelvic joints. A firm binder 
about the hips gave no relief. Tonics, sodium bromid, enemata, and 
hypnotics were given for the control of symptoms as they appeared from 
time tc time. 

By the eleventh of November the patient seemed nearly well. 
Discussion. — The case is afebrile, and apparently not of the renal 
or orthopedic groups. The pain is not affected by motion and, there- 
fore, is not due to lumbago. There is no evidence of sacro-iliac or spinal 
disease. The most definite and important feature in the case is the fact 



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Fig. 16. — Chart of case 32. 



LUMBAR PAIN 



J 03 



that the woman is debilitated, has lost 20 pounds in weight, is badly 
constipated, and probably has a wide-spread depression of other func- 
tions. There is no reason to suppose that the thyroid enlargement has 
any bearing on the symptoms. 

Nothing certain can be said regarding the diagnosis of such a case 
until the lapse of some time has made it clear that nothing else is going 
to develop. After this we may settle down more or less discontentedly, 
with the diagnosis of what some orthopedic specialists call a " functional 
back." This is a very familiar clinical entity, whatever its real cause 
and best nomenclature may be. 

Two things seem to me clear about this trouble: first, that psychic 
causes enter into it, and, second, that they are not the whole of it. For 
example, I have seen a young woman drag herself painfully down the 
street to the post-office with lumbar pain at every step, while each foot 
seems to weigh a ton and every muscular contraction is an effort. She 
calls at the post-office, gets a certain kind of letter, and walks home 
erect and free from pain. We are apt to say that such symptoms 
are imaginary, but this seems to me wholly unscientific. Certainly 
psychic causes enter powerfully into their production and destruction. 
May we not plausibly suppose that discouragement has slackened the 
muscles as it does those of a tired army on the march? A psychic cause 
renders them taut — a band of music, a long-expected letter; they there- 
upon begin to support the sagging joints, and the pain disappears as 
sensitive parts are relieved of pressure. It is in cases of this type that 
practitioners are apt to seek a cause for the symptoms in the pelvis, 
with what scanty justification I have endeavored to show in the intro- 
duction to this chapter. 

Diagnosis. — Debility. 

Case 33 

A metal polisher of thirty-six entered the hospital June 24, iqo8, 
because of pain in the back, beneath the twelfth rib, on both sides. 
This pain had been present for one week before entrance, accompanied 
by fever for the past four days, and vomiting for the past three days. 
Ten days ago micturition was frequent and painful for one day and the 
urine bloody. 

The urine at entrance showed much pus, a little; blood, a slight 1 

of albumin. The specific gravity varied between 1 00} and 1010. 

The twenty-four-hour amount was from (So to too ounces a day. An 

LOnal granular cast was found in the sediment. The leukocytes 

ranged from 16,000 to 19,000 per cubic millimeter. Widal's reaction 



io4 



DIFFERENTIAL DIAGNOSIS 



was negative; the range of the temperature and pulse was as seen in the 
accompanying chart. 

On physical examination the man was emaciated, pale, with sunken 
eyes. The edge of the spleen was easily felt. Physical examination 
was otherwise negative, except for considerable tenderness in both 
costovertebral angles. On the second of July a macular erythema 
appeared upon the back of the trunk and hands, and was seen by Dr. 
Charles J. White, who stated that he could not definitely recognize the 
nature of these macules. His bowels were moved by calomel and 
enemata, and he was given liquid diet. A culture specimen of urine 
showed a pure growth of colon bacilli. By the thirteenth of July pus 

had disappeared from the urine. The 
white cells were 8700. The Widal re- 
action was negative, as it was throughout 
the illness. 

Discussion. — The symptoms point 
obviously to the kidney, but the enlarge- 
ment of the spleen suggests the possibility 
of some other cause for the fever. With 
such a urine, with costovertebral tender- 
ness and leukocytosis, a urinary infection 
must form at least a partial explanation 
of the symptoms. Owing to the persis- 
tence of fever and the splenic enlargement, 
a routine blood-culture was taken, which, 
to everyone's surprise, showed typical 
typhoid bacilli. In view of this fact it may 
well be questioned whether the macular 
erythema was not, in fact, due to some 
form of typhoid rose spot — in other words, 
whether it was not due, like the ordinary crop of rose spots, to the 
lodgement of typhoid bacilli beneath the skin. 

Evidently we were dealing, in this case, with a double infection, both 
typhoid bacilli and colon bacilli being active pathogenic agents. The 
colon bacilli, in process of elimination from the body, presumably caused 
the renal infection. The lumbar pain was probably of the general 
infectious type, and not due to kidney lesion. 

Outcome. — The patient was given urotropin, 7 h grains three times 
a day, and left the hospital well on the twenty-sixth of July. 
Diagnosis. — Typhoid and colon bacillus infection. 




Fig. 17. — Chart of case 33. 



LUMBAR PAIN 



I05 



Case 34 

A laborer of thirty-nine entered the hospital June 11, 1907. 

In 1899 he wrenched his back in lifting a heavy jack, and was lame 
for three or four weeks afterward. In February, 1906, he had sciatica. 
For the past two months he has noticed an ache in his back when he 
gets up in the morning. Ten days ago he noticed tingling and numbness 
in his toes and the pain in his back increased. Since then he has slept 
very little, and six days ago he had to have morphin, which has been 
frequently used since then, but lately with only slight relief. 

Both legs, from the knees to the heels, are now sensitive and prickling. 
His feet feel freezing cold. He denies alcohol and venereal disease. 






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. 18. — Chart of case 34. 



Present Condition. — The range of temperature and pulse are as 
seen in the accompanying chart. The patient is well developed and 
nourished, but looks worn out and in much pain. Indeed, he can scarcely 
lie still a moment. The chest and abdomen show nothing abnormal. 
From the third to the eighth dorsal vertebra the backbone is bowed 
riorly. There is much tenderness on pressure over the seventh 

cervical spine. There is no disturbance of sensation in the feel or legs, 
and motion is everywhere normal. 

The urine is normal in amount, 1028 specific gravity, with the slight- 
est possible trace of albumin and a few finely granular casts. No blood 
or pus. The white cells number 14,800. The red blood-cells show 



io 6 DIFFERENTIAL DIAGNOSIS 

no stippling; x-ray is negative. The lines of expression in both sides 
of the face are flattened out. The right side moves less than the 
left. The patient cannot whistle, and protrudes his tongue slightly to 
the right. 

The grasp in both hands is equal, but markedly diminished. 

The knee-jerks are absent, the superficial reflexes normal, the mind 
clear. 

Discussion. — Clearly, we cannot blame the old wrench for the present 
trouble. The sciatica also seems to be ancient history, though both of 
these events may be of some importance as indicating a locus minoris 
resistencicB. 

In contrast with all the types of lumbar pain previously discussed 
this case stands out, marked by the presence of sensory symptoms (numb- 
ness and prickling) in the legs. It is also notable that the face and arms 
are affected, though not at the beginning of the case. 

Though the backward bowing of the spine brings the possibility 
of Pott's disease to mind, there is nothing else in this region to support 
any such hypothesis, and neither here nor in the cervical region, where 
some tenderness was present, did x-ray show any lesions. The entire 
absence of muscular spasm helps to exclude spinal tuberculosis. No 
other disease of bone or joint is definitely suggested, and there is nothing 
to point to the urinary system or to any general infection as the source of 
these troubles. The urine cannot be called normal, but its abnormalities 
are of a very vague and general nature, consistent with the presence of 
almost any disease and with the absence of all known disease, so that in 
this differential diagnosis they may be disregarded. 

In view of the general sensory symptoms, the loss of muscular power 
and tone and the diminished reflexes, multiple neuritis is the natural 
diagnosis. Were the spinal cord involved, one would expect pupillary 
changes, increased reflexes, relaxed sphincters, and the absence of such 
wide-spread sensory symptoms. 

As to the cause of the neuritis, we are here, as in so many other cases, 
quite in the dark. Alcohol and lead can be definitely excluded. There 
is no reason to suspect arsenic. The presence of moderate waves 
of fever and a continued leukocytosis makes it reasonable to suppose 
that an infectious process is at the bottom of the symptoms. 

Outcome. — The leukocytes continued to range high, and the pain 
and the tenderness continued to be very troublesome. Sterile water was 
given at times instead of morphin, and the patient was gradually weaned 
from his fondness for the drug. 

By the thirtieth of June the pains were less severe and could be con- 



LUMBAR PAIN 107 

trolled by aspirin, 10 grains, once or twice a day, or by placebos. There 
was moderate muscular wasting, and tenderness along the nerve-trunks 
was present. 

By July 8th the grip was much improved. The patient was up and 
about the ward, and soon went home to finish his convalescence. 

Diagnosis. — Neuritis. 

Case 35 

A negro of fifty, with a negative previous history, entered the hospital 
August 2, 1906, complaining that for three weeks he had been suffering 
from loss of appetite, nausea, fever, and weakness, and had been in bed 
a good deal of the time. 

Ten days ago he was beginning to recover his strength, but four days 
ago he suddenly began to have shooting pain in the lower back and but- 
tocks, the pains running down the backs of both legs, especially the left, 
and intensified by motion. He is fairly comfortable when quiet in bed. 
At the onset of his disease he took large doses of quinin with relief. 
His bowels now move every two or three days. 

On physical examination, temperature, pulse, and respiration 
were found to be normal, the chest and abdomen likewise normal, the 
blood and urine negative. Extension of the left leg with the knee 
straight caused marked pain in the left sacro-iliac joint. Movements of 
the leg with knee flexed were not painful. There was tenderness over the 
left sacro-iliac joint and over the lower dorsal spines. X-ray was nega- 
tive. The motions of the spine were markedly limited in all directions. 

Discussion. — Apparently the symptoms in this case followed a 
three weeks' febrile illness, the nature of which we do not know. The 
possibility of typhoid and a post-typhoidal spondylitis is naturally sug- 
gested, but if typhoid is often complicated by a late spondylitis, presum- 
ably other infections may have a similar sequel. 

The marked limitation of spinal motion and the tenderness in the 
lower dorsal region make it necessary to consider spinal tuberculosis. 
The negative v-ray, however, goes far to exclude this possibility. Only 
the course of time and the effects of treatment can make us more certain 
on this point. The same remarks apply to the possibility of malignant 
disease. 

Outcome. — Dr. Robert B. Osgood, who saw the ease in consulta- 
tion, considered it one of infectious arthritis of the spine and the left 

sacro-iliac joint; strapping of the back, with enemata and tonics, was 

the treatment. The patient was able to leave the hospital almost well 
in twelve days. 

Diagnosis.- Infectious spondylitis. 



I0 8 DIFFERENTIAL DIAGNOSIS 



Case 36 



A Swedish housemaid of twenty-five, with an excellent family history, 
entered the hospital March 27, 1907. She states that eight or nine years 
ago she was in bed for six weeks with "catarrh of the lungs," and that 
since she was ten years of age she has had frequent attacks of tonsillitis. 
Otherwise she has been well. At Christmas, 1906, she caught cold and 
was weak and feverish. At this time her back became very sore and 
painful on motion, and she had to give up work the first of January. 
Since then she has not improved at all, and has been in bed a consider- 
able part of the time. At entrance, the temperature, pulse, and respira- 
tion were normal, the chest and abdomen negative, the spine held rigidly 
and all motion painful. There was no kyphos and no sacro-iliac ten- 
derness. 

Discussion. — The long duration of the symptoms holds our attention 
at once. Chronic backaches may be due to functional causes, to osteo- 
arthritis and the pressure group (Pott's disease, new-growths, and aneur- 
ysm) . It is notable that in this case a rest in bed has not produced any 
marked improvement, neither has there been any alarming advance in 
the severity of the symptoms, such as would probably occur with malig- 
nant disease. The physical signs are confined to the evidence of a rigid 
and painful spine. Renal lesions and general infections are easily ruled 
out. Any ordinary lumbago would have been cured long before this. 
The spinal rigidity and tenderness make it very improbable that sacro- 
iliac disease is the only lesion present. 

The so-called functional, neurasthenic, or hysteric affections of the 
spine are naturally suggested by the long duration of the symptoms, by 
the age and sex, and by the absence of fever, kyphos, and other obvious 
lesions. The outcome of the case shows the great importance of not 
jumping at such conclusions until every method of physical examination, 
including the #-ray, has been used. This is especially true of all dubious 
and chronic cases. 

Outcome. — At entrance, the diagnosis was " acute osteo-arthritis 
with a neurasthenic background." An #-ray taken the first of April 
showed that the body of the second lumbar vertebra was extensively 
diseased, and a knuckle was later developed in the lumbar region. 
The patient was put at once into a plaster jacket, and by April 6th was 
able to sit up with comfort. On April 9th she left the hospital. 

Dr. Osgood's diagnosis was early Pott's disease. 

Di agnosis. — Vertebral tuberculosis. 




Fig. 19. — Area of pulsation at a point often overlooked in physical examination. Com- 
plaint, pain in the back. 



LUMBAR PAIN IOO 



Case 37 



A carriage painter of thirty-four entered the hospital March 20, 
1907. His father died of a paralytic shock; his family history was other- 
wise excellent. He remembers no sickness in his life. Had a soft sore 
eleven years ago, and a bubo about the same time; had no rash, sore 
throat, falling of hair, or pains following it, but was treated for a year 
after it, with what medicine he does not know. 

In his work he lifts from 100 to 200 pounds every day. He was per- 
fectly well until five months ago, when he began to feel weak. Since 
that time he has been losing weight and has done no work. Three 
months ago he strained his back, and since then he has had a burning 
pain in the small of his back and below the region of the heart on the 
left. This pain has increased considerably in the last three weeks, 
and is now so severe that he has to bend forward and to the left to ease it. 
It is made worse by walking, and interferes with sleep. He has no 
dyspnea and no other symptoms. 

Physical examination showed normal temperature and respiration; 
pulse somewhat accelerated, keeping most of the time between 100 and 
120. His pupils are equal and react normally; his heart and lungs 
negative, except as shown in the diagram (Fig. 19), his right radial pulse 
slightly larger than the left. 

There is resistance and dulness in the epigastrium, but no definite 
mass made out. The glands are considerably enlarged in the groins and 
axillae. 

Discussion. — As in the previous case, the element of duration is a 
most important one in the'diagnosis. A steady pain lasting three months 
is not likely to be due to functional causes when it occurs in a carriage 
painter of thirty-four. Lead-poisoning, suggested by the occupation, 
never produces such a pain as this without other symptoms. The general 
infections and the renal group of lesions are easily excluded by the physical 
examination. This leaves us with the diseases which I have called the 
pressure group (Pott's disease, aneurysm, and neoplasm) especially 
deserving of consideration. Only one diagnosis is possible in this case, 
provided it occurs to our minds at all. The danger is that it will not be 
thought of, and, therefore, will not be found in physical examination. 
Nothing but aneurysm produces an impulse and thrill with dulness and 
absent breathing between the spinal column and the left scapula. Pul- 
sating pleurisy and pulsating sarcoma do not present themselves at this 
point. 

Outcome. — A'-ray showed a distinct shadow in the area of pulsation, 



IIO DIFFERENTIAL DIAGNOSIS 

as figured in the diagram. The pain felt over the lower ribs in front 
seemed to be explained by pressure of aneurysm on the intercostal nerve. 

There is now no pain in the region of the tumor. The patient was 
given iodid of potash. 15 to 30 grains, four times a day; nitroglycerin, 
Tiro grain, every three hours; when needed for pain an occasional 
dose of morphin, | grain. 

The patient left the hospital slightly relieved on June 4th. 

Diagnosis. — Aortic aneurysm. 

Case 38 

A laborer of twenty-two entered the hospital July 4, 1906, with a 
negative family history. All last winter, he says, he suffered from 
"rheumatism around the heart"; otherwise his past history and habits 
are good. 

For the past two weeks he has been ailing, especially on account of 
pain in the abdomen, the back, the neck, or the head, every day. The 
pain in the back has prevented any continuous sleep for the last five 
nights, but he also aches all over, although he was able to work until 
two days ago. For the past week he has had a bad taste in his mouth 
in the morning. He says a number of his friends have the same trouble, 
and call it the "grip." His appetite is poor, and he has nausea after 
eating. The bowels are regular; there are no other symptoms. A soft, 
systolic murmur is heard all over the precordia, loudest in the pulmonary 
area. The pulses are of low tension and dicrotic. The chest and abdo- 
men are negative. On the forearms are a number of sharply defined 
macules and papules, which decolorize on pressure (mosquito bites?). 
In the left hypochondrium is a group of rose-colored macules, five in 
number. 

During the first three days of his stay in the hospital he had fever, 
ranging from ioo° to 103 ° F., accompanied by considerable pain in his 
back. 

Leukocytes were 5900; Widal reaction — persistently negative. No 
malarial organisms were found in the blood. The urine was negative. 
His abdomen was always rigid, and his bowels difficult to move. On 
the twenty-first of July, after four days of normal temperature, his back 
still showed limitation of motions in all directions, with considerable 
tenderness on his shins. A diagnosis of lumbago was made this day 
by Dr. Joel E. Goldthwait. Under criss-cross strapping his pain was 
almost gone by the twenty-fifth. His lips were cyanotic throughout 
his stay in the hospital; his appetite, enormous. 

His treatment consisted of salicylates and aspirin for the pain; also 



LUMBAR PAIN III 

the acetate and the iodid of potash, an occasional dose of morphin, and 
laxatives. At entrance he was treated as for typhoid. 

Discussion. — The diagnosis of lumbago is very plausible in this 
case, owing to the fact that the patient has general limitation of the 
lumbar motions, and has previously sulTered from stiff neck and other 
apparently muscular pains. But there are other features about the case 
which make it seem more like a post-febrile spondylitis of the type most 
often seen after typhoid. Lumbago does not produce a fever like that 
here described, and there are many other facts pointing to the existence 
of a general infection. The rapid recovery under a simple strapping 
treatment does not necessarily prove that the diagnosis is lumbago, but 
does tend to exclude all other possibilities, except the two above men- 
tioned. The cyanosis and the enormous appetite are not explained. 

Diagnosis. — Lumbago ( ? ) Infectious spondylitis ( ? ) 

Case 39 

An ice-man of twenty-five entered the hospital April 10, 1906. His 
family history was negative, his past history good. He had urethritis 
six months before. He has taken five or six glasses of beer a day, and 
one or two glasses of whisky a week, as a rule, but has seldom been drunk. 

Except for the urethritis, he was well until two weeks ago, when he 
began to have a dull, aching pain in the right side of his back and flank, 
not severe enough to make him give up work nor to keep him awake. 
After a couple of days this pain disappeared, but returned five days ago. 
This time it extended into the right leg, but not into the groin or testes. 
The painful area is tender, and the pain is constant. He has noticed 
no change in his urine; he thinks, however, that he passes more urine in 
the night than in the day. He has some shortness of breath and pal- 
pitation on exertion. 

He had no temperature above 99.5 ° F. during his stay of ten days in 
the hospital. The abdomen was held firmly above the navel, was every- 
where tympanitic, and in the right upper quadrant was tender. At this 
point a mass the size of the fist was felt, moving with respiration, 
apparently lobulated, and coming down a hand's-breadth below the ribs 
on full inspiration. It was easily felt bimanually, and could be partially 
replaced behind the ribs. 

The urine was between 60 and So ounces in twenty four hours, and 

conuiined a very slight trace; of albumin. In the sediment were many 

intracellular diplococci, decolorizing by Gram's stain. Twenty minims 

of the sediment of urine was inoculated into a guinea-pig. The anima! 

killed two months later, and showed no evidence of tuberculosis. 



112 DIFFERENTIAL DIAGNOSIS 

On the twentieth of April #-ray showed a definite shadow in the region 
of the right kidney. Dr. Davis catheterized the right ureter and ob- 
tained pus containing gonococci. 

Discussion. — Everything points to the kidney as the source of this 
patient's troubles. Our suspicions in that direction are promptly con- 
firmed as the result of cystoscopy, #-ray examination, and animal 
inoculation, a group of procedures demanded in almost every case of 
chronic renal pyuria. 

Since "surgical kidney" is excluded by the cystoscopic examination, 
and tuberculosis by the results of animal inoculation, the only important 
possibility left is renal stone, a supposition strongly supported by the 
#-ray evidence. 

Outcome. — The patient was transferred to the surgical ward and 
operated upon on May 2d. A stone was removed. The patient's 
convalescence took place without any incident and he was discharged 
May 26th. 

He was readmitted December 5, 1907. After leaving the hospital 
he was well and strong, and worked hard until three weeks ago, when he 
began to pass blood and pus in his urine and suffered pain in the right 
lumbar region, similar to that which he had previously had. He now 
suffers from two sorts of pain : (a) A dull ache in the right side, present 
most of the time; and (b) a stinging pain occurring only after micturition, 
starting from the urinary meatus and running up into the right side. 
The urine continued bloody for the first week of this attack, the last 
two or three spoonfuls of each discharge being bright blood with threads 
of yellow pus. Of late, no blood has been visible. He has lost appetite 
and has been very thirsty, although he has not been conscious of any 
fever. He has lost about 10 pounds in weight. The patient entered 
the hospital with a temperature of 102 ° F., pulse 120. After two days 
the temperature subsided to normal. His leukocytes were 10,000 at 
entrance. The abdomen was altogether normal, but in the right flank 
there was a visible prominence and a palpable, tender, dull, rounded, 
lobulated mass, apparently retreating under the ribs on pressure. 

The urine, as at the previous entry, was persistently of low gravity, 
ranging from ion to 1014, and rather large in amount — from 50 to 70 
ounces a day. The sediment was composed almost entirely of pus in 
moderate amounts. The pus persisted in his urine, and the patient con- 
tinued to have considerable pain in the right flank. X-ray showed only 
doubtful shadows of a possible stone. 

Operation, December 24th, showed no stone, but many pockets of 
pus scattered throughout the kidney, with smaller foci of round-cell 



LUMBAR PAIN 



113 



infiltration between them. The kidney was enlarged, and at one end 
was fibrous. Its pelvis was normal. The patient did well after nephrec- 
tomy. 

Diagnosis. — Renal stone; multiple abscesses. 

Case 40 

A housewife of fifty-one entered the hospital August 11, 1906, for 
the third time. At her first entry, in June, 1899, a diagnosis of gall- 
stones had been made; at the next entry, June, 1901, neurasthenia was 
the diagnosis. Her attacks of illness between February, 1899, and 
December, 1901, were very frequent and of a similar character. There 
was a sudden occurrence of pain, severe and cramp-like, doubling her up. 
It always started in the right side of the back, thence radiating to the 
right hypochondrium, but never to the right shoulder. It would last 
from two hours to two days, and was relieved occasionally by household 
remedies, but always by morphin. After relief there would be no 
recurrence for weeks or months. The pain was associated with vomit- 
ing-, but showed no special tendency to occur at night. The urine and 
feces were normal, and there was no fever with the attacks. Twice 
she entered the hospital for these attacks, but has always been free from 
pain while here. For the past two and a half weeks she has had an attack 
every day, sometimes in the afternoon, sometimes at night. Morphin 
has been injected several times, and she has had morphin pills on hand. 
Her bowels are moved daily, but she has had no appetite. 

Her physical examination, including blood and urine, temperature, 
pulse, and respiration, was wholly negative. On the thirteenth, at 3 A. M., 
she began to have severe pain. A rounded tumor was easily felt below 
the ribs, in the region of the gall-bladder, moving with respiration, and 
easily mapped out by percussion. 

Discussion. — Colicky pain in the right lumbar region naturally 
suggests renal stone. In the absence of any urinary changes, however, 
an jc-ray would be necessary to confirm the diagnosis. The account of 
the pain does not sound like that of lumbago, which is not promptly 
driven away by morphin, and is rarely so severe as to call for its use. 

Another cause for the pain is suggested by the rounded tumor in the 
right hypochondrium. This tumor might be connected with the Stom- 
ach or intestine, but the absence of gastric or intestinal symptoms be- 
tween the attacks of colic makes this unlikely. It seems more probable 
that the tumor is due to distention of the gall-bladder, tin- absence of 

jaundice being due to the fact that the common duct is patent. 

It is well to say a word in condemnation of the previous diagnosis 



H4 



DIFFERENTIAL DIAGNOSIS 



of neurasthenia, based, apparently, on the fact that the patient happened 
to be in the hospital during an interval between her severe attacks. 
Such a diagnosis, based wholly on negative findings, is always unjustified; 
for the patient it is often adding insult to injury. It is far better to make 
no diagnosis at all and watch for a recurrence of the previous symptoms. 

Outcome. — X-ray of the renal region was negative. On the fifteenth 
the abdomen was opened, and a number of gall-stones were found in the 
gall-bladder. 

Diagnosis. — Gall-stones. 

Case 41 

A longshoreman of forty-four with a good family history entered the 
hospital March 7, 1907. 

He had used a quart of ale daily until five weeks ago. In 1883 he 
had malaria in India. In 1890 he had blood-poisoning of the arm, and 
was in the Royal Infirmary, Liverpool, twenty-five days. 

Two years ago he had "pleurisy," and half a gallon of fluid was 
taken from his left chest. 

March 28, 1906, he had some operation done on his right testis, just 
for what cause he does not know. Since then he has been well until 
five weeks ago. He entered the hospital March 7, 1907, complaining of 
constant pain across the small of his back. It has been severe for the 
past two weeks, so as to prevent work or sleep. For a week he has had 
frequent cramps in his calves, and lately has been short of breath. He 
has lost 14 pounds in the five weeks. 

Physical examination of the abdomen showed in the right hypochon- 
drium and epigastrium two smooth, rounded masses, palpable biman- 
ually, descending with respiration. (See Figs. 20 and 21.) On inflation of 
the stomach the masses appeared to be behind it. Physical examination 
was otherwise negative, except that the urine was of low gravity — 1007 — 
ranged in amount from 70 to 120 ounces during the week of his stay 
in the hospital, and contained in its sediment a few hyaline and fine 
granular casts. X-ray of the spine was negative. 

The gastric contents contained no hydrochloric acid after a test- 
meal. The size of the stomach was normal, and there were no organic 
acids or fasting contents. 

Discussion. — The occupation is one of those often associated with 
lumbago or spinal osteo-arthritis, but for simple lumbago the pain 
has been rather too steady and prolonged. The question of osteo- 
arthritis will be referred to later. 

The history of pleurisy, together with a severe and long-standing 




Fig. 20. — Outline of masses felt March 8th, Cast- 41. (Sec also Fig. 21.) 




1. — Outlines recorded March 13th. Chief complaint, lumbar pain. (So 

i ig. jo.) 



LUMBAR PAIN 115 

spinal pain, often points to a spinal tuberculosis. It is quite possible, 
also, that the previous operation may have been for tuberculous epi- 
didymitis. Against this diagnosis, however, is the absence of fever and 
muscular spasm, as well as the negative x-ray examination. 

The two latter facts are also against the diagnosis of osteo-arthritis, 
though this cannot possibly be excluded. 

We naturally desire to connect all the symptoms and signs in the case 
into a mutually explaining group, and this brings us to the consideration 
of the abdominal tumors. Cystic kidney (congenital) would produce 
such a tumor and such a urine, but as it is invariably bilateral, we should 
expect to get some evidence of a tumor in the left hypochondrium. 
Further, cystic kidneys never cause pain in the back of anything like the 
severity here complained of. 

Hydronephrosis would explain the tumor, and possibly the urine, but 
would not account for the pain. 

Can the tumor be in the stomach, possibly with spinal or glandular 
metastases to account for the pain? This is suggested by the absence of 
hydrochloric acid in the gastric contents, but it must be remembered that 
a similar lack of hydrochloric acid has been frequently demonstrated in 
association with malignant tumors of any organ, e. g., cancer of the 
breast, as well as in a variety of debilitated conditions. Since no gastric 
symptoms are complained of, and there are no changes in the size or 
motility of the stomach, a gastric tumor seems unlikely. 

Retroperitoneal growths certainly deserve consideration. The 
previous tumor of the testis may well have been sarcoma, and if so, a 
metastasis in the retroperitoneal lymph-glands would be very likely. 
Further than this one cannot go without exploratory operation. 

Outcome. — The abdomen was opened on March 15th, and a retro- 
peritoneal mass the size of a grape-fruit was found behind the pylorus. 
It was afterward learned that the tumor of the testis was sarcoma. 

Diagnosis. — Retroperitoneal sarcoma. 

Case 42 

A medical student of twenty-three entered the hospital July 18, 1907. 

He had typhoid fever in the Massachusetts Hospital in August and 
September, 1906. After that he went back to college for the second 
half-year in February, 1907, taking his work easily, but finding it hard 
to concentrate his attention, having a good deal of pain in the forehead 
after studying, and needing to lie down every afternoon. On March 
1st he had an attack of severe pain in the small of his back; this lasted 

five days, with much stiffness* Four weeks ago he had another attack, 



n6 



DIFFERENTIAL DIAGNOSIS 



following exposure to cold and wet, lasting four days. For the past 
three weeks he has been in bed with the same trouble. Ten days ago 
he woke up in the night, doubled up with pain, and had to have morphin 
to relieve it. 

On physical examination the knee-jerks were found to be exaggerated. 
Kernig's sign was marked, and ankle clonus present. 

Temperature at entrance was 102 ° F., pulse, 120, but after forty- 
eight hours both pulse and temperature were normal. 

The white count was 3200; urine was negative. 

The spine was held rigidly in extreme lordosis, with well-marked 
spasm of the erector spinae group. The patient was unable to stand or 



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Fig. 22. — Chart of case 42. 



to sit erect. The hip motions were free and normal, except that hyper- 
extension of the right hip is painful. There is slight tenderness on pres- 
sure over the right sacro-iliac joint. 

Discussion. — A rigid, tender spine following typhoid fever and 
associated with some neurotic symptoms is almost the typical picture of 
post-typhoidal spinal arthritis. The chief objection to such a diag- 
nosis in this case is the long duration of the interval between the typhoid 
fever and the present symptoms. Almost all cases of "typhoid spine" 
come on within three months, while in this case the interval is almost 
six months. This, however, is by no means convincing evidence against 
the diagnosis. 



LUMBAR PAIN 



117 



In the earlier editions of Osier's text-book this disease was described 
as a neurosis without anatomic basis. The reason for this belief is sug- 
gested in the present case, as in the majority of all cases. Mental symp- 
toms, of the type usually referred to as neurotic or neurasthenic, consti- 
tute one of the varieties of post-typhoidal psychosis, and may be obstinate 
and long continued. Various types of insanity are also met with as 
sequels of typhoid, though nearly all of them recover. It is easy to see 
how mental depression, associated with muscular relaxation, might 
accent and aggravate the symptoms of an otherwise latent spondylitis. 
That spondylitis may be latent is proved by the occasional finding of 
rigid spines in patients who have never experienced any previous pain, 
and in whom v-ray demonstrates osteo-arthritic lesions. 

Outcome. — Dr. R. B. Osgood saw the case in consultation, and con- 
sidered it a typhoidal arthritis of the lower spine and sacro-iliac joints. 

On the twenty-third a plaster jacket was applied, with complete 
relief to the pain in the back. The patient had a good deal of vomiting, 
and for some days took nothing but cracked ice by mouth. At this time 
the urine showed a trace of albumin, with hyaline, granular, and epithelial 
casts in small numbers. 

The Widal reaction was positive. 

The second week of his stay in the hospital he had a rise in tem- 
perature (see accompanying chart) lasting five days. The patient was 
very hysterical, and a false chart hung at the head of his bed had a 
salutary effect. After the application of his plaster jacket he had no 
pain. On the eighth of August he was able to sit up in a chair. On the 
fourteenth he was discharged, much relieved. On the twenty-sixth of 
August he reported that he had been walking as much as twice a day 
without pain. He was still hypochondriacal and introspective, but was 
otherwise well. 

Diagnosis. — Typhoidal spondylitis. 

Case 43 

A Jewish housemaid of twenty, with a good family history and past 
history, entered the hospital September 2, 1907. She said that for tico 
years she had had a steady and rather severe pain in the small of the back. 
At the beginning of this period she was in bed for three months, after 
which she was able to work, although her back was stiff and her trunk 
bent toward the right. Last •'inter she had for several weeks a painful 

cough, without expectoration; she had no fever at any time. Although 
in constant pain, She has worked until three days ago. 

There was no fever. Examination of the chest and abdomen, 



Ilg DIFFERENTIAL DIAGNOSIS 

blood, and urine was negative. The left knee-jerk was considerably 
livelier than the right. The spinal muscles were rigid. 

Discussion. — The most important fact about this particular case of 
lumbar pain is that it has lasted far longer than any other hitherto 
described. Such prolonged suffering suggests either some member of 
the "pressure group" (aneurysm, tuberculosis, or neoplasm), or a func- 
tional neurosis; no general infection, no form of renal disease, and none 
of the orthopedic group of diseases would last so steadily and so long. 

A functional neurosis is not likely in a girl who keeps steadily at 
work, although in constant pain. The difference in the knee-jerks is 
also decidedly against this diagnosis. The patient is rather young either 
for neoplasm or for aneurysm. The muscular rigidity, the long duration 
of the pain, and the history of a previous cough support the suspicion 
of tuberculosis. 

Outcome. — Just below the level of the twelfth rib a knuckle the size 
of a small apple was later made out; it was very tender and hard, not 
red or hot. The patient was then in exquisite pain, but on the applica- 
tion of a plaster jacket was greatly relieved. 

Diagnosis.— Spinal tuberculosis. 

Case 44 

A married woman of fifty entered the hospital October 10, 1907. 
Her family history was good. She passed the menopause one year ago. 
Her menstruation has always been irregular, profuse, and painful. She 
has had no children and no miscarriages. In childhood she had rheuma- 
tism, typhoid fever, and abscesses on the forearm. For the past fifteen 
years she has had stomach trouble, symptoms consisting of lack of ap- 
petite, distress after eating, and constipation. For the past two months 
she has had frequent severe pains in the back, chest, neck, and legs; also 
occipital headache, "pins and needles" in the legs, noises in the head, 
buzzing in the ears, palpitation of the heart, insomnia, and great ner- 
vousness. Examination of the throat showed a linear aperture three- 
quarter inch long in the soft palate in the median line. 

There was anterior bowing of both shin bones, with roughening of 
their front surfaces, and three large white scars; also two or three deep 
scars on the extensor surface of the left forearm. Spinal motions were 
limited in all directions, but the pain was greatly relieved by strapping 
and rest. Dr. E. G. Brackett examined the spine and considered the 
trouble an acute infectious osteo-arthritis. 

Discussion. — In any patient who has such a multitude and variety 
of symptoms as this we naturally suspect a psychoneurosis, especially 



LUMBAR PAIN 119 

as the menopause has recently occurred. There are a number of data, 
however, brought out by the physical examination, which point in 
another direction. The hole in the soft palate is almost pathognomonic 
of old syphilis, especially when taken in connection with the scars on 
the extremities and the roughening and the prominence of the shin 
bone. 

There is no reasonable doubt, then, that this patient has suffered 
from syphilitic infection. The question remains whether this can ex- 
plain her present complaints. That syphilis may attack the spinal 
column has been satisfactorily demonstrated by x-ray evidence. At the 
same time, it is quite possible that her present troubles may be due to an 
acute infectious process of some other origin, or to purely functional 
derangements. Only by further observation and by noting the effects 
of treatment can the diagnosis be definitely established. 

Outcome. — The patient was also given sodium salicylate, 10 grains 
every hour, until toxic. Citrate of potash, 45 grains four times a day, 
until the urine became alkaline. Later, iodid of potash, 15 grains 
three times a day, increasing 10 grains daily, when the other drugs 
were omitted. 

Diagnosis. — Old syphilis; acute spondylitis. 

Case 45 

An Italian fruit-dealer of twenty-three is in the habit of carrying 
heavy loads, and thinks he has strained his back. He has never been 
sick otherwise, and has good habits and a good family history. He was 
first seen August 16, 1907. For five years he has had attacks of pain in 
the right side of his back almost every day. The pain is sharp, and he 
says it feels as if something was "rolling over" in his back. Six days 
ago the pain lasted all day. It never radiates to any other point, and 
has not often kept him awake. It does not hurt him to stoop. 

Physical examination was entirely negative, except for the presence of 
numerous musical rales, with slightly prolonged expiration throughout 
both chests. 

Discussion. — Muscular strain or lumbago is our first thought in this 

it was the patient's own explanation of his troubles. The long 

duration and paroxysmal occurrence of the symptom, however, and its 

independence of stooping, make this idea impossible. Any lumbar pain 

that lasts one of the pressure group irf causes, but 

physical examination does not bear this Out The pain should be steadier 

and less Intermittent were it due to pressure. The same considerations, 

together with the i of radiation or night attacks, tend to exclude 



120 DIFFERENTIAL DIAGNOSIS 

osteo-arthritis and sacro-iliac disease. The absence of local tenderness 
and urinary changes militates against the idea of renal disease. 

Vertebral tuberculosis was suggested by the prominence of certain 
vertebral spines, and by the doubtful phenomena in the lungs. The 
absence of any muscular spasm or tenderness makes this more unlikely, 
but x-ray should be taken in confirmation. On the whole, from the 
paroxysmal nature of the attack, some renal lesion seems the most 
likely. 

Outcome. — Aug. 19th there was no muscular spasm or tenderness 
about the spine or sacro-iliac joints, but he could not bend to the left as 
well as to the right. The vertebral spines from the eighth to the twelfth 
dorsal were slightly more prominent than their neighbors. There were 
slight prolongation of expiration and a shade of dulness at the right apex. 
Numerous musical rales were scattered through both chests. There was 
no fever. Blood and urine were still normal. 

Physical examination was otherwise negative. The patient was 
free from pain and said he felt perfectly well. X-ray showed a stone 
in the right kidney. Operation on the twenty-fourth verified this 
diagnosis. 

Diagnosis. — Renal stone. 

Case 46 

A housewife of twenty-three was first seen December 29, 1907. 
For three months she has been having pain in the left side of her back, 
worse at the menstrual period, and accompanied by constipation and 
general weakness. She has kept at work until two days ago. Family 
history, past history, and habits are good. The physical examination 
is negative in all respects. 

Discussion. — The chronicity and steadiness of the pain are like 
those often seen in spinal tuberculosis, and this disease can only be 
positively excluded by x-ray examination and by the course of the case, 
though it is made unlikely by the absence of muscular spasm of fever 
and of local tenderness or prominence. 

Kidney lesions cause unilateral pain like that here described, but 
there is no further evidence to support any such hypothesis. 

The orthopedic group of lesions is excluded by the mobility of the 
spine and the absence of local tenderness. 

Since there is no fever, we have no good reason to suspect any infec- 
tious disease. 

If the x-ray proves negative, the case must be treated as one of func- 
tional pain, while we await further developments. 



LUMBAR PAIN 121 

Outcome. — After a week's rest in bed with German powder as a 
laxative the patient's symptoms were entirely relieved, and as the #-ray 
was wholly negative, she was allowed to resume work. 

Diagnosis. — Debility. 

Case 47 

A blacksmith of thirty-one was seen July 21, 1906. Seven days ago 
he began suddenly to have sharp stabbing pains in the lower part of both 
chests and on both sides of his back, and was unable to take a deep 
breath on account of the pain. Three days ago he gave up his work. 
Two days ago he went to bed. He has felt feverish, especially at night; 
for the last two days has had general headache and has slept poorly. 
Just before the onset of the present illness a horse had thrown him heavily 
against a building. He had a negative past history and family history 
and good habits. 

On physical examination the pupils were found to be equal and to 
react normally. The chest showed nothing abnormal. The abdomen 
was full and rather rigid, but showed nothing else of interest. The 
spleen was not palpable. Flexing the neck caused pain in the back, but 
there was no rigidity of the neck muscles and no Kernig sign. 

The white cells were 5200. Stained specimen negative. Widal 
reaction and blood culture negative. The urine was normal. 

The temperature ranged between 102.5 ° an< ^ io 5-5° F. for ten days, 
the pulse gradually rising from 100 to 120, the respiration most of the 
time ranging between 40 and 50 to the minute. The abdomen became 
more distended, and on the twenty-fourth the patient developed delirium 
and tremor. On the twenty-sixth his neck was found to be entirely 
rigid, though rotation was possible without pain. 

Discussion. — The onset of the present symptoms immediately 
after an accident makes it natural that we should attempt to connect 
them with some injury then sustained, but the negative visceral exam- 
ination and the presence of continued fever make it probable that 
the accident had nothing to do with the case. 

I have known tertian malaria to begin exactly in this way, with sharp 
Btabbing pain in the lower part of both chests, but in that case the char- 
acteristic course of the fever, with remissions on alternate days, quickly 
led me to examine the blood and to demonstrate malarial parasites. In 
the present case the temperature curves and the results of blood examina- 
tion enable us to exclude malaria. 

With the rapid onset of thoracic pain, fever, headache, and acceler- 
ated respiration we should consider pneumonia, which may be present 



122 DIFFERENTIAL DIAGNOSIS 

even without demonstrable signs in the chest and without leukocytosis. 
Within a few days, however, repeated and painstaking examinations of 
the lungs usually demonstrate some evidence of solidification, even 
when cough and sputum are absent. No such signs developed in this 
case. 

Typhoid fever was the diagnosis made during the first five days of 
the patient's illness, and in the absence of all physical signs, with con- 
tinued fever and low white count, this was probably as good a guess as 
we could expect to make. With the appearance of stiffening of the neck 
on the twenty-sixth of July the diagnosis was promptly changed to 
meningitis, though the condition known as meningismus complicating 
typhoid was also a possibility; indeed, between meningitis and menin- 
gismus — i. e., between cerebral congestion and actual exudation of the 
pus-formation — we have no certain way of distinguishing. 

Outcome. — Kernig's sign and leukocytosis appeared next day, and 
the delirium ceased, though a low muttering and twitching of the arms 
continued. Lumbar puncture was tried on the twenty-seventh, but 
no fluid was obtained. 

Throughout, the patient's behavior was strikingly like that seen in 
typhoid. Death occurred on the second of August. 

Autopsy showed acute purulent leptomeningitis ; septicemia (strep- 
tococcus pyogenes); hypertrophy and dilatation of heart; septic hyper- 
plasia of the spleen; obliterated extra ureter on the left side; fatty meta- 
morphosis of the liver; fibrous cord from umbilicus to the mesentery. 

Case 48 

An unmarried seamstress of nineteen entered the hospital January 
25, 1908. The girl had never been sick until a few days ago, when she 
began to have pain in the small of the back, relieved by lying down, a good 
many headaches, and an occasional vomiting spell. There was no 
costovertebral tenderness ; the urine was negative. The spine was nor- 
mally flexible without pain, and no tenderness in the sacro-iliac joints 
could be elicitated by any maneuver. Fever was absent. The cata- 
menia had been absent for three months. 

Vaginal examination showed a mass the size of a horse chestnut, 
reddened and eroded, protruding slightly from the vulva, but reducible. 
In the posterior culdesac was a mass the size of a large apple, not at all 
movable, apparently in the back of the uterus. There was milk in the 
breasts, and the areolae were darkly pigmented. Under light ethei 
anesthesia it was easily possible to free the fundus from the sacrum 
and to put the whole organ into normal position. Examination then 




Fig. 23. — Signs as recorded in Case 49. Lumbar pain is the chief symptom. (See also 

Fig. 24.) 




Fig. 24. — Results of physical examination of the chest in a case of lumbar pain. (See 

also Fig. 23.) 



LUMBAR PAIN 1 23 

showed a normal uterus enlarged about the size of a three and a half 
months' pregnancy with a very soft, patulous cervix. 

Discussion. — In the absence of all the causes of lumbar pain hereto- 
fore discussed, and in view of the amenorrhea, a pelvic examination was 
obviously indicated. The only remaining question is whether the 
symptoms are likely to have been due to the condition of the uterus. 
The anatomic position of the displaced and enlarged organ as here 
described seems to me to put it in a different category from any of the 
minor pelvic disorders to which I have previously referred as unlikely 
of themselves to cause lumbar pain. The question seems to me solved 
in all reasonable probability by the — 

Outcome. — The patient was entirely relieved by these procedures. 

Diagnosis. — Prolapsed, retroverted, incarcerated, pregnant uterus. 

Case 49 

A Russian housewife, twenty-eight years old, entered the hospital 
December 10, 1908, complaining of sharp pain in the back and on both 
sides of the chest below the ribs, which has lasted a week. She has 
also had a cough for the past three weeks. She is eight months' preg- 
nant. At entrance her temperature is 101 F.; pulse, 125; respiration, 
32. She is slightly cyanotic. The heart's apex is in the fifth interspace, 
anterior axillary line, 14 cm. to the left of midsternum. A harsh systolic 
murmur is heard at the apex and in the axilla. The pulmonic second 
sound is accentuated. The superficial veins over the chest are very 
prominent. Near the junction of the second rib with the sternum on 
each side are seen tortuous arteries which pulsate visibly. In the lower 
left axilla there is flatness, absence of breath-sounds, and fine crackling 
sounds. (See Fig. 24.) The abdomen is distended as by a pregnant 
uterus. A fetal heart is heard in the left lower quadrant; rate, 148. 
The pain in the back is intermittent. 

Discussion. — Only one question need be seriously considered in 
this case. Is the pain due to an infectious disease or to the contractions 
of a pregnant uterus? 

Infection is suggested by the fever, the three weeks' cough, and the 
signs in the left lower axilla, which are quite consistent with a pleurisy. 

On the other hand, the intermittence of the pain is what we should 

I if it coincided with uterine contractions. The next thing to do, 

then, is to watch the patient continuously with the hand over the uterus, 

bethei the pains coincide with the uterine movements. In a 

somewhat similar case, occurring in a young, neurotic Jewess six and a 

half months pregnant, and suffering also from a moderately advanced 



124 



DIFFERENTIAL DIAGNOSIS 



tuberculous process in the lung, I stood by the patient, with my hand 
upon the abdomen, until I convinced myself that the lumbar pain was 
dependent upon her restless movements and not upon uterine contrac- 
tions. In this latter case the patient went on to full term, though the 
tuberculous process developed ominously. 

Outcome. — On observation the pain was soon determined to coincide 
with uterine contractions. On December 12th she gave birth to a 
seven-and-a-half-pound boy. 

Diagnosis. — Parturition. 

Case 49a 

Called May 9th, 191 1, to a girl eight years of age, who complained 
of severe pain in back and thighs, with difficulty in walking. The 
father is addicted to the too liberal use of intoxicants, but is otherwise 
in good health. Mother in good health. The patient is the third 
child in a family of seven children, all living and well. On questioning, 
it appeared that two days before, while playing at school, she was 
thrown down a bank ; she thinks that the vertebrae in the dorsal region 
struck a stone. No history of any previous illness or injury could be 
obtained. She had pain in the back during the forenoon of the injury, 
and while walking home at noon she lay down beside the road for 
some time because of the pain in back and legs, and the consequent 
difficulty in walking. She felt unable to return to school in the after- 
noon, but went as usual the next day. 

On the third day she was seen by a physician. The brows were 
then contracted, the eyebrows raised at their inner ends, and the 
muscles of the face rigid. There was stiffness of the back and legs. 
When she was turned on her side the legs would remain separated, 
with no support for the upper one except the tonic spasm of the 
muscles. The hands were rigidly flexed at the metacarpophalangeal 
joint. There was no anesthesia. No signs of injury along the spine 
or elsewhere on the body were found on casual examination. At 
this time a consultant saw the case and was unable to decide be- 
tween myelitis and meningeal hemorrhage. 

Next morning there was a general muscular tonic spasm, lasting 
one or two minutes, with involuntary micturition and defecation. 
The mind was perfectly clear. This condition continued for about 
twelve days, the temperature varying from ioo° to 102 F., with several 
tonic convulsions daily. The jaws were not tightly closed, but would 
not open over a third of an inch. The respirations were " grunting" 
in character, and during the spasms there was marked cyanosis. No 



LUMBAR PAIN 1 25 

cough. The patellar reflexes were present at the time of the first 
examination, but were not tried for after that. Physical examina- 
tion (including the urine) was otherwise negative. 

Discussion. — In view of the history of trauma to the spine, 
one thinks first of some abnormal pressure upon the cord, perhaps a 
hemorrhage. But with hemorrhage into the cord one would expect 
a more definite localization of the symptoms below the level of trau- 
matism. The muscles of the face would not be affected as they are 
here. Paroxysmal and general tonic spasm is also uncharacteristic 
of hemorrhage into the cord. Fracture of the spine seems to be 
excluded by the physical examination and by the free power of 
locomotion. 

In view of the presence of fever, pain, and muscular weakness, 
with relaxation of the sphincters, acute myelitis or poliomyelitis might 
be considered. The latter is easily excluded by the absence of definite 
paralysis and the very widespread tonic spasm. In transverse mye- 
litis or diffuse inflammation of the cord, anesthesia or other sensory 
symptoms are almost always present, and convulsions with involve- 
ment of the face are, so far as I know, unknown. 

The muscular spasms present in this case have something in com- 
mon with those seen in poisoning by strychnin, which may have been 
taken accidentally or with suicidal intent. Continued fever, however, 
is not usually present in strychnin-poisoning. The face is not often 
involved and the sphincters are rarely relaxed. No strychnin was 
found in the house, and none had been given therapeutically. 

Uremia may be ruled out by the absence of changes in the heart 
and blood-pressure, and the negative urinary examination. 

Epileptic convulsions may occur, as in this case, without loss of 
consciousness, but so far as I know they almost always include clonic 
as well as tonic spasms, whereas in this case clonic motions were alto- 
gether absent. Continuous fever without loss of consciousness is also 
rare in epilepsy. 

Hysteria may produce tonic spasm not unlike that here described, 
but is practically never associated with continued fever nor with 
involuntary micturition and defecation. 

A rigidly resistant condition of all the muscles is sometimes seen 
as a feature of the negativism in dementia praecox, but this disease can 
here be ruled out by the great suddenness of this patient's attack 

without any accompanying or preceding mental abnormalities, and 

by the present e of continuous fever and relaxed sphincters. 

With the exclusion of all these possibilities one naturalh comes 



126 DIFFERENTIAL DIAGNOSIS 

to ask one's self what infectious disease can produce fever like that 
here present, associated with widespread muscular tonic spasm. 
Obviously tetanus is such a disease, but we have no history of any 
wound or injury whereby the bacillus of tetanus could have been 
introduced. There has been no subcutaneous injection of any sub- 
stance which could contain the tetanus bacillus as an impurity (e. g., 
diphtheria antitoxin, gelatin). Nevertheless cases are on record in 
which it was not possible to discover the portal of entry for the bacil- 
lus, though such a portal had to be assumed, since the bacillus was later 
isolated from the tissues. It is not generally believed that infection 
can enter through the gastro-intestinal tract. On the whole, tetanus 
is the best choice among available alternatives. 

Outcome. — After the diagnosis of tetanus had been decided 
upon and tetanus antitoxin administered, repeated and prolonged 
inquiries were again instituted regarding any previous injury, and it 
was learned that two weeks before the onset of symptoms there had 
been an abrasion of the knee from the edge of a rough board; a sliver 
had been removed and the wound had healed. A closer examina- 
tion of the knee was accordingly made; it revealed a small bluish 
area on the inner side of the right knee, posterior to the hamstring 
and superficially healed except for one small spot from which a drop 
of pus could be expressed. This area was incised and curetted and 
a further sliver of wood about one- third of an inch in length was 
thus found and removed. The wound was swabbed out with iodin 
and a second injection of antitoxin administered. No cultures were 
made. On the fifteenth day of the illness the patient was convales- 
cent, and twenty-four days from the onset was well. There had been 
marked loss of flesh and a decidedly round-shouldered condition of 
the upper spine persisted; also occasional muscular pains. 

Diagnosis. — Tetanus. 



LUMBAR PAIN 



127 






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CHAPTER IV 
GENERAL ABDOMINAL PAIN 

The diagnosis of the causes of abdominal pain is one of the most 
unsatisfactory, as well as one of the most important, in medicine; 
unsatisfactory, because our methods of examination are so inadequate. 
The chest, the cranium, and the extremities present far less difficulty, 
partly because their diseases are more accessible to direct inspection, 
partly because (in relation to thoracic disease) we have developed the 
technic of auscultation, percussion, and #-ray examination to a point 
quite out of the question in dealing with the belly. Our methods of 
investigating the abdomen are rough and primitive compared to those 
for the study of the chest. 

Aside from the information obtained by study of the urine, blood, 
gastric and intestinal contents, practically all our knowledge depends 
upon palpation and a good history of the case. The latter is of crucial 
importance in this diagnosis of gall-stones, peptic ulcer, gastric cancer, 
colica mucosa, and many other common diseases. Palpation is mate- 
rially assisted by immersing the patient in a bath as hot as he can bear. 
In some cases the procedure gives us almost as complete a relaxation 
of the belly walls as can be obtained under anesthesia. It should be 
employed in all dubious abdominal cases (questionable tumors, unex- 
plained pains, etc.), especially if spasm of the muscles makes ordinary 
palpation difficult. 1 

Further reference will be made at the end of this chapter to another 
obstacle to correct abdominal diagnosis; namely, the tendency of local 
lesions to produce generalized pain, and of generalized lesions to pro- 
duce localized pain. These obscure radiations often deceive even the 
expert. 

Case 50 

A clerk of thirty-nine, of good family history and habits, entered the 
hospital January 31, 1907. He had rheumatic fever eight years ago. 
Three and one-half years ago he was doubled up by an attack of 
pain and aching all over his bowels. He was seen in the Brockton 
Hospital by Dr. Daniel F. Jones, who said it was not appendicitis. 
Since this attack he has been well up to three weeks ago, when, after 
lifting, he had a stitch in his back, could not straighten up, and had to 

1 Women can be protected by making the water opaque with soapsuds. 
128 



Causes of General Abdominal Pain 



■i^^^MHHHMH^^M^Mi 2761 

661 



2. DIARRHEA AND i 
ENTERITIS I 



3. APPENDICITIS HUn^H 451 

4. TYPHOID H^H 379 



5. GENERAL PERI- j 

TONITIS i 

6. LEAD-POISON-) 

ING i 



11. NEUROSES 
GASTRIC 



237 



169 



7. INTESTINAL) 

OBSTRUC- 
TION, I N- 

CLUDINGH 167 

STRANGU- 
LATED HER- 
NIA J 

8. TUBERCULOUS] 

PERITONITIS 

AND TABES Hi 108 

M E S E N- 

TERICA 

9. TABES GAS- 

TRIC CRISIS 



42 



0. EXTRA- ^ 

UTERINE'! 29 

PREGNANCY ^ 



1 1 



Among the rarer cause- are manv vari- ties of abdominal tumor (which usually pro- 
luce local rath- r than generalized pain), malaria (especially in children), and spinal tuber- 



GENERAL ABDOMINAL PAIN 131 

stop work. The pain in his back was eased by lying down, and has not 
recurred. His bowels have since been very costive; hence after taking 
laxatives without result he took two injections, which caused cramps in 
the abdomen so severe that he "almost went crazy." The doctor came, 
gave him some " dope," and explained that he had appendicitis or gall- 
stones. He is very nervous and sleeps poorly. He has sometimes a 
voracious appetite. 

Physical examination showed good nutrition and slight pallor. Tem- 
perature, pulse, urine, and blood normal. The patient was a cribber. 
Physical examination was entirely negative, except for slight tenderness 
in both iliac fossae. There was considerable mucus in the feces, bind- 
ing the whole stool together into a single tenacious mass, like sputum. 
The patient was very much afraid of appendicitis, and complained fre- 
quently of terrible pain relieved by cooking soda. Guaiac test persist- 
ently negative. 

Discussion. — Appendicitis is and should be our first thought in any 
case beginning with such symptoms, but the suspicion is shown to be 
groundless by the absence of elevation of the pulse, temperature, or 
leukocyte count, and by the fact that there is no tenderness or spasm 
in the appendix region. 

Inflammation of the gall-bladder is ruled out for similar reasons. 

Lead colic is consistent with all the symptoms here mentioned, but 
no such diagnosis can be made in the absence of all other evidence that 
lead is in the system (lead-line, stippled red corpuscles, occupation in- 
volving lead). 

Pain relieved by cooking soda is often the result of duodenal ulcer, 
a disease always to be thought of in patients with acute abdominal 
symptoms. The history and the physical examination, however, offer 
no confirmatory evidence. No blood has apparently been discharged, 
either by the mouth or by the bowels, and we have not the usual history 
of long-standing digestive disturbance. Mucous colitis or colica mu- 
cosa is a diagnosis consistent with all the symptoms here described. 
The chronic constipation, the suggestion of a neurotic constitution, 
the occasional attacks of severe abdominal pain, and the presence of a 
large amount of mucus in the stools passed soon after such pain com- 
plete a typical picture of this disease. 

Three groups of cases are often met in practice: 

(1) Those with much nervousness, some pain, and some mucus. 
'I hose of much pain, some nervousness, and some mucus. (3) 
Those of much mucus, some nervousness, and some pain. 

In all three groups constipation is the underlying factor. Treat- 



132 DIFFERENTIAL DIAGNOSIS 

ment must be directed to the relief of this and of the accompanying 
neurosis. 

Outcome. — His points of tenderness varied from day to day, but at 
no time did he have tenderness in the right iliac fossa. After his bowels 
got to moving regularly, the pains disappeared and he gained 4 pounds 
inside of a week. Simultaneously his urinary excretion increased from 
30 to 60 ounces. He left the hospital well on the eleventh of February. 

Diagnosis. — Neurosis; mucous colitis. 

Case 51 

A stenographer of twenty-four entered the hospital March 26, 1908. 
Six years ago she had six attacks of cramp-like pain in the abdomen, 
each lasting six or eight hours, and relieved by morphin. The pain was 
not localized in any one place, but after an attack she had soreness in the 
left lower quadrant. Since that time she has had a more or less con- 
tinuous "hard ache" in the left lower quadrant, never moving to any 
other place. She also has stiffness in both legs down as far as the knees. 
Her pain is not aggravated by motion. She has had no vomiting at any 
time. Working at the typewriter seems to cause cramp-like pains in the 
stomach. On account of these she was operated on in August, 1907, 
for appendicitis, and was told that "chronic appendicitis " was found 
and cured. The pains have continued as before. Her appetite and 
sleep are good, but she is markedly constipated. Last August she 
weighed 126 pounds; now she weighs 118. She often has pain on mic- 
turition, and occasionally difficulty in passing her urine. 

On physical examination her pupils are widely dilated, equal, and 
react normally. The gums are normal. There is a short, rough, 
systolic murmur heard all over the precordia and in the left axilla. 
There is no enlargement of the heart nor accentuation of the pulmonic 
second sound. The abdomen is negative; likewise the blood, urine, 
temperature, pulse, and respiration. 

Discussion. — The gist of this case seems to be: non-localized ab- 
dominal pain, with a negative physical examination in all essentials. 
Lead-poisoning is easily ruled out by the absence of changes in the blood 
or in the gums. Since the pupils react normally, tabes dorsalis seems 
very unlikely, though there is nothing said about the reflexes in the 
description as given above. 

Dilatation of the pupils is common in a great variety of psycho- 
neurotic states; nevertheless, it should always suggest the possibility of 
a cocain habit, especially if any heart trouble is complained of or comes 






GENERAL ABDOMINAL PAIN 1 33 

to light on physical examination. In the present case there was no such 
evidence, and the habit was hrmly denied. 

In a considerable number of cases of pulmonary tuberculosis there 
is dilatation of one or both pupils, and the presence of this sign always 
leads me to examine the pulmonary apices with particular care. In 
this case such an examination was negative. 

The controverted question of chronic appendicitis is raised afresh in 
this case, but I suppose no one will maintain that an appendix can 
produce symptoms seven months after it has been removed. When 
the patient's symptoms persist unchanged after the removal of a so- 
called chronic appendix, it is generally agreed upon that in this case 
the appendix was not the cause of the symptoms. Indeed, this is one of 
the few points regarding chronic appendicitis on which physicians do 
very generally agree. Personally, I believe that in a considerable pro- 
portion of the cases operated upon as chronic appendicitis the ap- 
pendix has nothing to do with the symptoms. The disappearance of 
symptoms following operation is not always a proof that the appendix 
was the offending member. The operation itself, with the postoperative 
rest, diet, physical and mental training, may well have been the cause 
of the relief. 

In the present case, if we take account of the age and sex, the marked 
constipation, and the variety of "wild symptoms," such as painful 
micturition and stiffness of the legs, it seems more than likely that a 
general neurosis based on faulty habits and unfortunate environment 
is at the root of all the troubles. The domestic and industrial back- 
ground should be looked into. 

Outcome. — On further investigation it appeared that insufficient 
food, hurry, worry, and sedentary occupation in a close office had much 
to do with her condition. All the reflexes were lively. 

Diagnosis. — Bad hygiene. 

Case 52 

A Russian Jew, apparently without occupation, forty-eight years old, 
entered the hospital December 26, 1907. For seven weeks he has been 
having pain and "burning" in the center of the abdomen, not very m.-\ en , 
but constant and worse at night, though he sleeps v. ell. It is worse, also, 
immediately after eating. Mis appetite is poor; he has taken nothing 
but a little mill: of late. His bowels arc very irregular, usually con- 
stipated, lie docs not vomit or COUgh. 

( )n physical examination a regularly distributed, rose-colored macular 
eruption is found in various parts of his body, and there are marks of 



134 



DIFFERENTIAL DIAGNOSIS 



scratching on the upper arms. The chest shows nothing abnormal. 
Beneath the umbilicus, and extending out toward the right flank, is a 
smooth, rounded, cylindric mass, about three inches long, one and a 
half inches wide, freely movable, not hard or tender, feeling not unlike 
a kidney. Physical examination, including the blood, urine, tempera- 
ture, pulse, and respiration, is otherwise entirely negative. 

Discussion. — The important objective findings are the macular 
eruption and the cylindric mass in the abdomen; the former suggests 
syphilis, the latter, an abdominal tumor. Against syphilis, however, is 
the itching of the eruption, as evidenced by scratch-marks. There is 
also no evidence of a primary lesion, and the patient denies all knowledge 
of the disease. 

Russian Jews in general, and unoccupied Russian Jews in particu- 
lar, are very prone to neuroses and vague unexplained pains. It is 
striking how often they refer to these pains as "burning." "Es brennt 
mir das Herz," or "Es brennt mir liberall," are very common com- 
plaints among them. 

It is noteworthy also that this pain, though worse at night, does not 
prevent him from sleeping well. 

Turning now to the abdominal mass, we note that it occupies the 
position in which a displaced kidney is often to be felt, especially in 
women. It seems, however, rather too short and too little sensitive. 
In view of his chronic constipation a mass of retained feces may well be 
the explanation. It seems reasonable, then, to explain his indigestion, 
eruption, and anorexia as the result of constipation, the latter in turn 
being the commonest of all manifestations of a general neurosis. 

Outcome. — The patient was given an A. S. and B. pill, and the next 
morning the tumor had entirely disappeared. The following day it 
was again felt just at the level of the umbilicus, and considerably smaller 
than at entrance. Similar masses were then felt in the left iliac fossa. 
These also disappeared with free movements of the bowels. On Decem- 
ber 31st his abdomen was wholly negative, his eruption gone, and he 
had a wonderful appetite. 

Diagnosis. — Constipation. 

Case 53 

A storekeeper of twenty-six, of good family history and habits, 
entered the hospital October 17, 1907, stating that he had always had a 
weak stomach and had been troubled by pains in the chest and limbs 
off and on for the past ten years. Nevertheless he kept about and did 
his work in this condition until January, 1907, when he was confined to 



GENERAL ABDOMINAL PAIN 



135 



bed for fifteen days by an attack of pain "in the lungs and back." In 
March he was again confined to bed for two days with pain across the 
upper abdomen. In April and May he felt poorly, but kept at work. 
In June he first noticed general abdominal tenderness and considerable 
enlargement, with painful micturition. He was then in bed for three 
weeks. After that he worked until August, when he was suddenly 
taken with violent headache, chills, sharp pain under the left breast, in 
the back and in the loins, with enlargement of the abdomen. He 
remained in bed thirty-five days, his temperature rising every afternoon 
to 102 ° F. or 102.5 ° F. He sweated profusely every night. Since then 
he has been poorly and his night-sweats have continued, but the size of 
his belly has diminished. During the past nine months he has lost 
11 pounds in weight. He had at times a slight cough, with sputa rarely 
blood-specked. During the past few days there has been slight swell- 
ing of his legs. 

Examination of the lungs and heart showed nothing abnormal. 
The abdomen was symmetrically distended; there was slight tympany 
in the flanks; the belly elsewhere was dull, tense, firm, slightly tender 
throughout. There was vague resistance at and about the umbilical 
region. 

The blood and urine showed nothing abnormal, and the temperature, 
pulse, and respiration were not elevated during the seven weeks of his 
stay in the hospital. After the injection of 5 milligrams of tuberculin 
there was no rise of temperature, but he felt sick and weak, and his belly 
became much more tender. 

Discussion. — Chronic abdominal pain and tenderness, with fever 
and sweating, form a clinical picture characteristic of very few diseases 
occurring in the male sex. Subphrenic abscess may produce such symp- 
toms, but not without further physical signs, either in the abdomen, 
near the costal margin, or in the chest through displacement of the dia- 
phragm. Perforative peritonitis could not be so chronic without either 
healing or killing. 

Typhoid fever might produce such a pyrexia, and would account for 
most, if not ail, of the abdominal symptoms, but during his stay in the 
hospital his abdominal symptoms continued despite the absence of all 
fever. Typhoid would not explain this. 

Can he be suffering from chronic intestinal obstruction? The 
abdominal pain and distention BUggest it, but his bowels have moved 
regularly throughout There has been no vomiting, visible peristalsis, 
or other evidence of local lesioo. 

in my own experience there are only two diseases which present a 



136 DIFFERENTIAL DIAGNOSIS 

clinical picture at all like this: (a) The psycho-neurotic state, and (b) 
abdominal tuberculosis. Since the former can be ruled out by the five 
weeks of daily fever, only one diagnosis seems reasonable. 

Outcome. — On the second of November the spine of the fifth dorsal 
vertebrae was found to be very tender on pressure. This, in connection 
with the fact that sitting erect caused sharp pains in the chest and 
abdomen, suggested spinal tuberculosis, but an orthopedic consultant 
thought it more likely to be glandular tuberculosis in the abdomen. 

Two other consultants thought the symptoms probably due to 
chronic appendicitis. 

On the sixth of December the abdomen was opened, and the in- 
testines found to be everywhere adherent to each other, to the omen- 
tum and to the abdominal wall. A large chain of glands was matted 
together in the appendix region, and many others were scattered about. 
There was no fluid. Microscopic examination of a piece excised showed 
tuberculosis. 

Diagnosis. — Peritoneal tuberculosis. 

Case 54 

A housewife of forty-four who had been in the hospital in May, 1905, 
and been operated on for inflamed tubes and ovaries (which were 
removed), chronic appendicitis, and sigmoid adhesions, entered the 
hospital February 20, 1908. Ever since May, 1905, the symptoms 
which then led to operation have persisted. She has been treated in 
the medical, surgical and orthopedic departments for out-patients, and 
has worn flat-foot plates and abdominal supporters without relief. 
She has been unable to do any work on account of soreness in the lower 
abdomen, together with sharp attacks of pain starting in the back and 
passing around the sides to the center of the abdomen. These attacks 
come on when she steps or moves quickly, even when she turns over in 
bed at night. The pain is somewhat less sharp when her bowels are 
open, but she is exceedingly constipated. She complains of a " drawing, 
scratching " feeling in her bowels, as if they were trying to move, but could 
not. She has gained 20 pounds since the operation at which the tubes 
and ovaries were removed. 

Physical examination shows extreme obesity, slight tenderness in 
the left lower quadrant of the abdomen, and nothing else, except slight 
soft edema over the shins. 

Discussion. — In an analysis of "One Hundred Christian Science 
Cures, " printed in McClure's Magazine for August, 1908, I pointed out 
that patients who have had many doctors and many diagnoses are very 



GENERAL ABDOMINAL PAIN 1 37 

apt to be successfully rounded up and cured by Christian Science, owing 
to the fact that in such cases no organic disease is present. 

The history of the present patient and of the vicissitudes through 
which she passed suggest that she belongs in this group. Doubtless 
many of her symptoms represent only the discomforts inseparable from 
extreme obesity, especially when it is associated with constipation. 

If this be true, the question may be asked how the edema of the 
leg is to be accounted for, but I think it is generally recognized that obesity 
is in itself sufficient to account for such a swelling, without supposing 
any insufficiency of the heart or kidneys. 

Doubtless this patient's symptoms are due in part to the nervous 
instability often following the removal of the ovaries, but the constipa- 
tion, the obesity, and the firmly acquired "doctor habit" are also im- 
portant factors. 

Such a diagnosis, though satisfactory enough from our point of view, 
may be of very little use to the patient, whose sufferings often go on 
unabated unless we can succeed in the almost superhuman task of 
changing most of her habits, mental and physical. 

Outcome. — When the patient is alone in the ward, she does not seem 
to suffer, but her complaints are very numerous whenever a doctor or a 
nurse approaches. She complains that she is restless at night, but 
snores loudly. A tight abdominal binder and vibratory massage 
had relieved her considerably by the eleventh of March. 

Diagnosis. — Postoperative neurosis. 

Case 55 

A school-boy of nine was first seen September 23, 1907, with the state- 
ment that he had never been sick before, except that six months ago he 
had an attack similar to the present. Seven days ago he began to have 
general abdominal pain. Five days ago the pain was much aggravated, 
and seemed to be more troublesome on the right side of the abdomen. 
Four days ago he had a sore throat. His appetite has been good; his 

is regular. He has had no headache or nai. 
Kxamination September 23d was negative, except for a temperature 
of 103.6° F., and the leukocyte count of 22,000, with a negative Widal 

ion. There was at that time slight tenderness ;it and above 

M< Burney's point. 

September 26th the fever still continued; physical examination was 

ive in all respects. The Widal reaction was negative; white cells, 

8400; the course of the temperature was as shown in the accompanying 
chart. 



138 



DIFFERENTIAL DIAGNOSIS 



Discussion. — During the early days of my attendance on this case 
I could make no diagnosis. The fever, the leukocytosis, and the ab- 
dominal signs favored appendicitis, though the absence of all spasm 
and of all but very slight tenderness in the appendix region made this 
doubtful. The sore throat was practically gone before I saw him, and 
could not be held responsible for the symptoms then present. 

On the twenty-sixth, however, the clinical picture had quite changed. 
Continued fever with a low white count and a negative tuberculin reac- 
tion were now the essential features. This means, in all probability, 
either typhoid fever or some of the unknown infections unwisely called 
"febricula" or "grip." The latter possibilities were soon ruled out 



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by the long duration of the fever. Under the hypothesis of typhoid fever 
it was left for us to explain the initial leukocytosis and the absence of the 
Widal reaction. No such explanation, however, was then forthcoming. 
The phenomena just referred to remained as examples of the wild, 
untamed, residual items so characteristic of any accurately described 
case of illness. 

Outcome. — On the third of October the Widal reaction appeared. 
On the eighth he was given a drop of tuberculin in the left eye, without 
any subsequent reaction. 

On November 9th he was discharged well. 

Diagnosis. — Typhoid. 



GENERAL ABDOMINAL PAIN 1 39 

Case 56 

A Portuguese housewife of thirty-two entered the hospital October 
25, 1907, with a negative family history and good habits. She had a 
miscarriage two years ago, and two other miscarriages since her marriage 
three years ago. She has one healthy child. For seven years she has 
been subject to general abdominal pain, not severe. 

Three weeks ago she began to have dull, steady pain, starting in the 
left lower quadrant, whence paroxysms of more severe pain extended 
across the abdomen and up both sides of the chest to the neck. The 
appetite is poor; there is occasional nausea, but jao vom iting. The 
bowels are constipated. For the past three weeks micturition has been 
somewhat painful. 

Physical examination shows obesity. The chest is normal, the 
abdomen tympanitic in the upper part, dull in the lower part, where 
tenderness is so great that palpation is impossible. The blood-pressure 
is 100 millimeters of mercury; the white count, 14,900. Urine, tern- -^ 
perature, pulse, and respiration are normal. During the week of her 
stay in the hospital she complained of pain in every part of her body. 

Discussion. — Syphilis is the first possibility that occurs to us in this 
case, in view of the frequent miscarriages. It is impossible, however, 
to incriminate any particular organ or to obtain any more definite history 
of the disease, which must remain in the background as a possibility 
incapable, at present, of further verification. 

We naturally ask ourselves next whether the abdominal tenderness 
and painful micturition are not due to gonorrheal infection of the tubes 
and bladder. This possibility cannot be absolutely excluded, but in the 
absence of fever, leukocytosis, and urinary changes, it seems decidedly 
unlikely. 

The very wide distribution and radiation of the pain, and its asso- 
ciation with vomiting, constipation, and anorexia, lead us to conclude 
that if any inflammatory lesion has existed in the pelvis it is now burnt 
out and exerting its effect chiefly through the nervous system. 

Outcome. — A few nights before her discharge she was rolling and 
groaning with pain, but a subcutaneous injection of sterile water gave 
immediate relief. Vaginal tampons also improved her mental condition. 

Obviously, the therapeutic test was here of considerable diag- 
nostic value. I believe, however, that the same important information 
can be obtained through the investigation of the psychic state, and 
without any of the charlatanry which seems to me inherent in the methods 
here employed. 

Diagnosis. — Neurosis. 



140 



DIFFERENTIAL DIAGNOSIS 



Case 57 



A factory girl of twenty-six, a Canadian by birth, was first seen 
May 28, 1907. In April, 1906, she had a sickness similar to the present 
one. At that time medication gave no relief, but a six weeks' vacation 
in Roxbury entirely relieved her. Her home is in Blackstone, Mass. 

In March, 1907, she began to have dull, colicky pain and tenderness 
in the lower part of her abdomen, constant, showing no relation to meals 
nor to the kind of food eaten, often keeping her awake at night, usually 
relieved by pressure. Frequently she has to sleep upon her belly all 

night. With the pain she has constipation, 
and has noticed that she is getting pale. 

On physical examination the abdomen 
was full, soft, tympanitic throughout, and 
showed no tenderness at any point. The 
chest was likewise normal. A blood-smear 
showed 60 per cent, hemoglobin, some 
achromia and many stippled cells. 

The urine averaged about 25 ounces in 
twenty-four hours, and contained a trace 
of albumin, many hyaline and granular 
casts with an occasional cell adherent. 

Discussion. — Although this case puz- 
zled a number of physicians, there would 
have been no puzzle about it but for the 
neglect of a routine blood examination, 
for there is only one disease which often 
produces basophilic stippling of the red 
cells in the absence of marked anemia. 
That disease is chronic lead-poisoning. Other diseases (e. g., diabetes) 
have been known to produce a similar blood-picture, but this is rare. 

Lead-poisoning is a very common disease, but the failure to recognize 
it is, in my experience, still commoner. This is not because it is difficult 
of diagnosis, for the very reverse is the case, but because physicians so 
often fail to suspect its possibility and to examine patients for definite 
evidence of its presence. When once our attention is turned toward this 
diagnosis, we shall note, as in the present case, a very striking group of 
confirmatory signs. A chronic abdominal pain relieved by pressure 
would be likely to have more relation to meals if it were due to duodenal 
ulcer or to any cause other than lead. Association with constipation, 
pallor, and albuminuria should certainly make us search for a lead line 



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GENERAL ABDOMINAL PAIN 141 

on the gums — one of the signs which is most often forgotten in routine 
physical examination. 

Outcome. — The gums showed a typical lead line. Her mother and 
sister have a similar but less severe trouble. The patient was given 
magnesium sulphate, an ounce every morning; iodid of potash, 5 grains 
three times a day, and an occasional dose of morphin and atropin was 
also needed. Turpentine stupes relieved her pain more or less. 

By June 6th her appetite had improved, her cramps were gone, and 
her color had begun to return. 

By the ninth of June she was ready to go home. It appeared that 
the whole family got their water from a well through a lead pipe 75 feet 
long. 

The reader will note the striking rise in pulse-rate and its continued 
rapidity after the first week of treatment. The bradycardia of plumb- 
ism has often been recorded, but never, I think, satisfactorily explained. 

Diagnosis. — Lead-poisoning. 

Case 58 

An Italian meat-cutter of thirty-five was seen June 20, 1907. He 
stated that he had never been sick before until a year and a half ago 
(six months after his arrival in this country) , when he began to notice that 
his abdomen was slightly larger than normal. He also noticed a beating 
in the pit of the stomach with vague abdominal pains, much loss of 
strength, occasional chills, and slight fever. At times his abdomen has 
seemed to be swollen, but of late it has been smaller. The pain is steady, 
dull, worse on dark, cold days. He is easily fatigued and has done no 
work for six months, but his weight has remained steady. He has had 
dizziness and buzzing in his head for three months, and for one month 
night-sweats. He eats and sleeps well, but his bowels move only witli 
laxatives. 

Physical examination of the chest was negative. The abdomen 
showed dulness in the left flank, which, however, did not shift with 
change of position. There was slight tenderness in the region of the 
umbilicus. Near this tender point a violent pulsation was felt, synchro- 
nous with the heart-beat. It was expansile in character, and during pal- 
pation a systolic thrill could be appreciated over it. A systolic murmur 
audible at the same site. The tuberculin reaction (subcutaneous) 
entirely negative. The urine averaged about 22 ounces in twenty- 
four hours, was free from albumin, but contained rare hyaline and gran- 
ular casts. Blood examination was negative; white cells, 7000. Tem- 
perature, pulse, and respiration were normal. 



!42 DIFFERENTIAL DIAGNOSIS 

Discussion. — In the presence of chronic abdominal pain with swell- 
ing of the abdomen, weakness, night-sweats, and constipation, the pos- 
sibility of tuberculous peritonitis should always be entertained, espe- 
cially when the patient is an Italian recently settled in America. In the 
present case, however, the absence of fever at the present time, the 
negative tuberculin reaction, and the fact that no characteristic lesions — 
either of "dry" or of "wet" tuberculosis — can be detected in the abdo- 
men make this diagnosis unlikely. 

More plausible is the idea of aortic aneurysm, and this was, in fact, 
the diagnosis of the attending physician. Against it, however, were 
two very important facts: the pain was in the wrong place and there 
was no tumor. The pain of abdominal aneurysm is almost entirely in 
the back and legs. Further, the diagnosis of aneurysm is never well 
grounded unless we can feel a definite tumor with a beginning, middle, 
and end. However violent the pulsation we may find in the abdomen, 
— and I have seen it sufficient to shake the bed in which the patient lay, — 
we have no right to make the diagnosis of aneurysm unless we have, in 
addition to the pulsation, a definite tumor or severe pain in the back. 
Expansile pulsation, thrill, and systolic murmur can be appreciated over 
any abdominal aorta which is superficial enough to be reached with the 
fingers and with the stethoscope. 

It seems almost incredible that an illness so prostrating as this 
could be produced by the mere accident of having one's attention di- 
rected to the normal, though lively, pulsation of one of one's own blood- 
vessels; but such was really the case here. Dynamic aorta — that is, 
a somewhat unusual liveliness in the pulsation of a perfectly normal 
blood-vessel in a person of neurotic constitution — is very frequently 
mistaken for abdominal aneurysm. Indeed, I should say that five out 
of every six cases in which I have known the diagnosis of abdominal 
aneurysm to be made have turned out to be nothing but dynamic aorta. 
Nothing but the experience of following such a case to complete and 
lasting recovery, as the result of the policy of disregarding all the symp- 
toms and turning the attention in other directions, can convince the 
patient and his physician of the facts just quoted. 

In true abdominal aneurysm the tumor is seldom in the median line. 
It is much larger and more globular, and pulsates less violently than the 
dynamic aorta. One of the most astonishing things about the latter 
is that it often appears just beneath the skin of the abdominal wall, 
seemingly separated from our finger-tips only by the thickness of a piece 
of blotting-paper. As we recall our dissecting-room experiences, it 
does not seem possible that the aorta can lie so close to the abdominal 



GENERAL ABDOMINAL PAIN 143 

v r all. Doubtless this is due to a somewhat atypical curve of the spinal 
column. 

There can be no doubt, I think, that three factors enter into the pro- 
duction of the neurosis known as dynamic aorta: 

(1) An unusually superficial position of the abdominal aorta. 

(2) A sensitive and impressionable temperament, such as shows 
itself in rapid bodily motion, quick excitable speech, lively knee-jerks 
and easily excited heart action. 

(3) The abnormal concentration of attention upon the pulsation. 
This latter condition is favored by the physician's obvious interest and 
concern, as expressed in his careful and repeated examinations of 
the part, his overclouded countenance, and sometimes his unguarded 
utterances. If by any mischance the patient begins to suspect that he has 
an aneurysm, he is pretty sure to learn from a dictionary or otherwise 
what the disease really means. Thereafter he passes his days and nights 
feeling very much as though he had inside of him a dynamite bomb 
which might explode at any minute. This, of course, reacts upon his 
mental condition, and makes him watch himself all the more care- 
fully, thereby increasing the pulsation and soon leading to the develop- 
ment of pain; but it should be reiterated that the pain is in the spot to 
which his attention has been directed, and not in the place where it 
would be were aneurysm really present. 

I have dwelt at considerable length upon the nature of this trouble 
and the means of its recognition, because it is by no means uncommon, 
is prone to lead to a great deal of unnecessary misery when mistaken for 
aneurysm, and because it is not treated at any length in most text-books. 

Outcome. — Gas in the abdomen and the perception of the pulsating 
artery were apparently the cause of his symptoms. This was explained 
to him, and by June 27th he was free from complaint. He returned to 
work after ten days more and has since (1910) remained well 

Diagnosis. — Dynamic aorta. 

Case 59 

A printer of twenty-seven entered the hospital August 19, 1907. 
His family history and habits are good. lie states that he had "renal 
colic" last May for two days, and has since then been well. Two weeks 
ago his bowels began to be rather loose. I lis appetite has remained good 
and he has slept well. Beginning this morning he has had severe ab- 
dominal cramps, his bowels have moved six times, and he has vomited 
six times. The pain is felt throughout the abdomen. 

Ph; unination Bhows two glands the size of marbles in the 



144 DIFFERENTIAL DIAGNOSIS 

right axilla. No other glands seem to be enlarged. There is a soil 
systolic murmur at the heart's apex. The chest is otherwise negative. 
The abdomen is slightly retracted. There is general muscular rigidity, 
especially in the epigastrium, and in the right side near the navel. On 
percussion the belly is tympanitic, except in the left flank — no definite 
mass or tenderness found. Temperature at entrance 99.8 F.; white 
count, 16,600, with 96 per cent, of polynuclear cells. The next day 
the temperature and the white count were normal. The diarrhea had 
ceased. 

Discussion. — What further evidence should be searched for in this 
case? In any printer who complains of abdominal pain we should at 
once look for a lead line on the gums and search for basophilic granula- 
tions in the stained blood-smear. Both these lesions were absent in this 
case. The presence of diarrhea is also very uncommon in lead-poison- 
ing. 

An x-ray examination is indicated in view of the patient's statement 
that he had renal colic a few months before. There is nothing, how- 
ever, pointing to any such disease in a physical examination. 

Perforative peritonitis would account for the pain, vomiting, fever, 
leukocytosis, spasm, and tenderness, but the presence of a diarrhea with 
good appetite and sleep makes this very unlikely, especially as there is 
no local point of maximum pain and tenderness. 

But for the definite evidence afforded by the blood examination, it 
would be necessary to consider an acute lymphoid leukemia. I have 
seen leukemia presenting the symptoms here described with no more 
striking glandular enlargement. The blood examination, however, 
was distinctive. 

Why should it not be a simple gastro-enteritis, especially in view of 
the time of year at which the symptoms occurred? Severe abdominal 
cramps, a general muscular rigidity in the abdomen, transitory fever 
and leukocytosis are all quite consistent with that diagnosis; there 
seems to be nothing of importance against it. 

Outcome. — X-ray showed no evidence of renal calculus, after rest 
in bed and regulated diet, ten half-grain doses of calomel, and an ounce 
of magnesium sulphate, the patient was discharged well on the twenty- 
second. 

Diagnosis. — Acute gastro-enteritis. 

Case 60 

A teamster of forty-four, with a negative family history, was first 
seen August 24, 1907. 



GENERAL ABDOMINAL PAIN 1 45 

For many years he has been in the habit of taking from twelve to 
twenty glasses of beer and three to five glasses of whisky daily. He 
chews a five-cent plug of tobacco a day, and smokes three or four pipef uls 
besides. He has always been very well and strong until five months 
ago, when he began to have dull pain in the abdomen, not definitely 
localized, but more marked in the lower half. This was accompanied 
by distress and flatulence after meals, and frequent vomiting imme- 
diately after the taking of food. The vomitus is bitter, yellow-green, 
never blood}-. His appetite is poor, his bowels constipated, and he has 
been short of breath for the past four weeks. For the past two weeks 
he has had to pass his urine twice each night. Two years ago he weighed 
155 pounds; to-day he weighs 121. 

On physical examination the skin is dry and satiny. There is a 
marked alcoholic odor on the breath. The arteries are all palpable, 
and there is a lateral pulsation in the brachials. The chest and ab- 
domen showed nothing abnormal. 

Kxamination of the blood showed red cells, 2,030,000; white cells, 
7200; hemoglobin, 25 per cent. The stained specimen showed achromia, 
slight poikilocytosis, many off-colored cells, no nucleated red cells. 

The urine was negative. After a test-meal the stomach-contents 
showed no free hydrochloric acid. The gastric capacity was 23 ounces. 
His stools were brownish-black, with a well-marked reaction to guaiac. 
Rectal examination was negative. The prostate was not enlarged. 

Discussion. — The excesses in alcohol and tobacco above described 
would naturally lead one to suspect cirrhosis of the liver. The long- 
continued gastric symptoms, as well as all the minor complaints, could 
be thus explained. The guaiac reaction in the feces might be the result 
of blood poured out from dilated veins in the esophagus or stomach. 
Against this supposition, however, is the extreme degree of anemia, with- 
out any history of severe hemorrhage. Even if the blood were dis- 
charged by rectum, the patient would probably be made aware by faint- 
weakness, and thirst, of the loss of an amount of blood sufficient 
to explain the present anemia. It is unusual, furthermore, that a cir- 
rhosis disables the patient and produces such marked symptoms as are 
here present, without manifesting itself by any change in the size of the 
liver or by the accumulation of ascites. 

Whenever a patient past forty years of age, and previously free 
from Stomach trouble, begins to have any sort of gastric discomfort, 

or mild, gastric carcinoma should be considered. This diagno- 

lain all the symptoms in this case, including the anemia. 

It i- remarkable, however, that there should be no more definite e\ idence 



i'» 



X46 DIFFERENTIAL DIAGNOSIS 

of gastric stasis, no food in the vomitus or in the stomach-washings. 
If cancer is present, it is probably not at the pylorus — its usual seat. 

So extreme a degree of anemia, associated with gastric symptoms 
and achylia gastrica, brings the thought of pernicious anemia to mind. 
The blood, however, is very uncharacteristic, and is, indeed, typical 
of secondary anemia. 

On the whole, gastric cancer is the most probable diagnosis. 

Outcome. — On the morning of the twenty-seventh of August the 
right middle finger was blanched and cold up to the knuckle-joint. 
Examination of the patient in the warm bath showed a sharp edge in the 
region of the liver, descending with respiration. (See Fig. 27.) 

On the third of September the abdomen was opened, and an inoper- 
able cancer of the anterior stomach- wall found. The mass thought to 
be liver before operation proved to be part of the gastric tumor. 

Diagnosis. — Cancer of the stomach. 

Case 61 

An Italian shoemaker of thirty-two has complained for a year of 
general bellyache with diarrhea, at times bloody. Much intestinal 
noise. Has lost 28 pounds in two months. For the past week he has 
been costive. 

Examination was negative, excepting for a palpable spleen and a 
hemoglobin of 65 per cent. During his fortnight under observation 
(September 1-14, 1904) he had no fever, no diarrhea, and gained eight 
pounds. He had slight abdominal pain, especially at night. There was 
slight tenderness in both iliac fossae. Colitis, possibly tuberculous, was 
the diagnosis in the out-patient department and in the wards. 

Next spring (May 22, 1905) he was again at the hospital. His 
pain, he said, had never ceased. Constipation has been obstinate 
and is getting worse. The rumbling noises are still loud. He has 
lost 14 pounds since his previous entry. 

Slightly above the region of the cecum is a firm, regular mass, about 
the size and shape of the kidney, freely movable in all directions, dis- 
tinctly tender on pressure. No reaction to tuberculin (two large doses) . 
Stools foul, watery, no blood, no tubercle bacilli, some mucus. 

Discussion. — In view of the information which came to light when 
this patient entered the hospital for the second time, there are only two 
diseases to be considered as at all likely to produce these symptoms, 
viz., cancer of the cecum and pericecal tuberculosis. The latter is made 
unlikely by the negative reaction to tuberculin. 

The interesting question remains: could the cancer which now 




Fig. 27. — Diagram of the- findings in Case 60. Chief complaints, dull abdominal pain. 

vomiting, and flatulence. 



GENERAL ABDOMINAL PAIN 



147 



shows itself at the cecum have been suspected in 1904? Certainly no 
positive diagnosis of this disease could have been made, but it seems to 
me that whenever we have the history of very loud and marked intestinal 
noise, accompanied by pain experienced at short intervals throughout a 
year's time, we ought to suspect that some sort of disease has caused 
intestinal stricture with muscular hypertrophy of the gut behind it. It 
is true that in many cases of diarrhea from colitis intestinal noise is 
heard, but it is especially in the acute varieties that we meet with this 
symptom. In cases lasting a year it is much more uncommon. Again, 
a good many women are troubled by intestinal noise at the time of the 
menstrual period, or whenever they are especially nervous, but the process 
is never so continuous as in the present case. 

Except for this symptom, the diagnosis of chronic colitis was certainly 
justifiable in 1904. The case, however, reenforces in a striking way the 
well-known rule that in all long-standing diarrheas intestinal obstruction 
should be suspected, especially, but not exclusively, in elderly people. 
It is, of course, a very familiar fact that many cases of cancer of the sig- 
moid begin with diarrhea. 

Despite such warnings as are given us by a case like this, the diag- 
nosis of intestinal cancer is often entirely impossible with our present 
methods of investigation. There is good reason to believe that it is 
often present and quite latent for years. The symptoms we see are 
merely terminal. For example, a patient whom I saw in 1906 for pain 
high up in the rectum, accompanied by discharges of blood and mucus, 
had been troubled by severe periodic pains with considerable constipa- 
tion, referred to appendicitis, for at least fifteen years. At the autopsy 
in June, 1907, cancer of the sigmoid was found, but no appendicitis. 
In another group of cases the patient is aware of the presence of 
tumor in the abdomen for three or four years, without any pain or dis- 
turbance of the bowels, yet the tumor turns out on exploration to be 
cancerous. Xot infrequently pain may be referred to the pit of the 
stomach, and so closely associated with ordinary gastric symptoms 
that all our attention is drawn in that direction. 

Outcome. — Dr. Conant diagnosed tuberculous colitis and advised 
operation. 

A growth the size of an orange was found in the cecum (adeno- 
carcinoma by microscopic examination) and excised. Discharged well 
June 23d. 

A year later (June 5, [906) he returned. The operation had given 
relief for months, and he had gained 20 pounds, but of late pain and 
bloody >too!s have returned, this time in the left lower quadrant, where 



I4 8 DIFFERENTIAL DIAGNOSIS 

there is a mass i by 2 J inches, and tenderness. Operation showed 
inoperable cancer of the sigmoid. Cecal region normal. Inguinal 
colostomy. Discharged July 7, 1906, to out-patient department. 
Diagnosis. — Recurrent intestinal cancer. 

Case 62 

A boy of eleven was seen September 28, 1903. Since his third year, 
when he had malaria, he has had fleeting pains in his arms and legs, 
especially at night. The feet often show toe-drop. 

For three months he has been troubled with attacks of bellyache, 
accompanied often by chill and vomiting and by an increase in the 
troubles in his arms and legs. 

Twice he has had tonic-clonic convulsions. 

Discussion. — When a child has a stomachache in summer, it would 
be folly to conclude that malaria is the cause; but it is equal folly not to 
suspect that malaria may be the cause. For some unknown reason the 
malarial attacks of children and of young adults are much more likely 
to be atypical than those of older persons. 

(a) Malaria often exists in children without producing any symptoms 
at all, and is demonstrated only by blood examination. 

(6) In many cases it produces only a recurrent headache and list- 
lessness, due, in fact, to a rise in temperature every twenty-four or forty- 
eight hours, without any chill ("dumb ague"). 

(c) Vomiting recurring at regular intervals, daily or every other day, 
has been the only suggestion of malaria in some of my cases until the 
blood was examined. 

(d) An intractable diarrhea is sometimes associated with a malarial 
infection of the blood, and promptly cured 'by the administration of 
quinin. 

(e) Abdominal pain of the type exemplified in this case is perhaps 
the most common of the atypical manifestations of malaria. In some 
cases it is localized in the right iliac fossa. In one week's service at the 
Massachusetts General Hospital three patients were sent in to be operated 
upon for supposed appendicitis. All of them had malaria, and were 
promptly cured by quinin. These have been referred to by Dr. James 
M. Jackson, in his article published in the Boston Medical and Surgical 
Journal, June 26, 1902. I have already referred, in the discussion of a 
previous case (see p. 121), to a case of malaria beginning like pneu- 
monia with violent thoracic pain. 

(/) In adults we not infrequently see cases of malaria with predom- 
inating cerebral symptoms, such as acute mania or coma. 



GENERAL ABDOMINAL PAIN 



149 



Now if malaria can assume such a bewildering variety of clinical 
aspects, what is to guide us toward correct diagnosis. I should answer 
*.hat in practically all these atypical forms a thorough blood examination 
should be suggested by the presence of an irregular fever and the low 
leukocyte count. Enlargement of the spleen and the firm, painless edge 
which the organ presents to the palpating finger are generally to be recog- 
nized in these cases, and should also put us upon our guard against 
malaria. The therapeutic test is valuable, but should not be abused by 
continuing to pour quinin into the patient at the rate of 20 to 40 grains 
a day for a week or more. This is not a therapeutic test: it is a stupid 
blunder. Two or three days is enough to settle the matter in 999 cases 
out of 1000, and in the remaining case no further information is obtained 
by prolonging the administration of quinin. 

Outcome. — The blood was found to be swarming with tertian para- 
sites. Wrist-drop and toe-drop. Knee-jerks absent. 

Diagnosis. — Tertian malaria. 



Case 63 

A woman of fifty, a lawyer's clerk, entered the hospital January 2, 
1906, stating that she had had many attacks similar to the present one, 
but had always been able to work. Two days ago she 
felt some abdominal discomfort in the afternoon. Early 
yesterday morning she awoke with a sharp, steady pain, 
especially in the right side of the abdomen, but not 
definitely localized. This was accompanied by disten- 
tion and obstinate constipation. Last night the pain 
was felt in the left side. She has vomited several times, 
and has slept poorly on account of pain. (For tem- 
perature, see chart.) 

The abdomen is distended, tympanitic, and generally 
tender; white cells, 4600; urine, 1029; a very slight 
trace of albumin; many fine, granular casts. Physical 
examination was otherwise negative. A glycerin enema 
and hot-water bottle to the abdomen gave her some relief, 
but on the morning of the fourth, the temperature 
continuing to rise, though the white cells were still only 
4000, she was operated upon. 

Discussion. -A definite diagnosis was impossible 
but the general appearance of the patient made it 
clear that she was very ill, while the course of the symptoms went on 

<ly from bad to worse. It was for these reasons that the 



Fig. 28. — Chart 
of 1 asc 63. 






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GENERAL ABDOMINAL PAIN 



151 



the finer points revealed by blood examination the picture is one of 
secondary anemia. 

Any case presenting these symptoms demands a very careful examina- 
tion of the rectum and lower sigmoid by means of a speculum, since 
cancer of this part of the gut is a frequent cause of all the symptoms 
here presented. 

Outcome. — Through a rectal speculum with an adequate light a 
large cauliflower mass could be seen nearly occluding the upper part of 
the rectum. From it there was a foul serosanguineous discharge. An 
excised bit proved to be cancer. 

Diagnosis. — Cancer of the rectum. 

Case 65 

An active, muscular young man of twenty-six, a machinist by trade, 
had always been perfectly well until three years ago, when he had an 
attack of acute appendicitis for which an operation was performed. 
A five-inch incision was necessary; the wound was drained for a long 
time, and later a large ventral hernia developed. Thereafter he seemed 
perfectly well until five days ago, when he had an attack of acute general- 
ized abdominal pain lasting for about eighteen hours, and accompanied 
by constipation. He was then perfectly well for the two succeeding 
days, when a second attack of pain came on, accompanied by nausea 
and vomiting. This had persisted nearly twenty-four hours when he 
was seen in consultation. 

When examined, the head, chest, and extremities showed nothing 
remarkable. The abdomen was slightly tender throughout, and there 
was a moderate amount of spasm not localized. Attacks of colicky 
pain, now here, now there, but for the most part in the umbilical region, 
recurred every few minutes. There was no bulging at the seat of the 
scar, and no palpable mass anywhere. There was slight dulness in the 
flanks, which shifted with change of position. The temperature was 
normal; the pulse no and of low tension. The face was drawn and 
showed evidences of severe pain; indeed, the patient looked exceedingly 
ill. The blood and urine showed nothing abnormal. There was no 
lead-line on the gums. An enema brought away a small movement, 
normal in character. 

Discussion. — Intestinal obstruction and genera] peritonitis are the 
most likely hypotheses. There is nothing in his occupation nor in the 
examination of the blood and the gums to make lead-poisoning at Ml 

probable. If perforative peritonitis were present, there would be 
apt to be more tenderness and some fever. Yet I have several times seen 



152 DIFFERENTIAL DIAGNOSIS 

acute virulent peritonitis demonstrated without any fever or tenderness. 
We have no evidence pointing to any source for peritonitis, and nothing 
to connect the symptoms with the stomach or the gall-bladder, while 
the appendix has already been excluded surgically. What can we argue 
from the presence of shifting dulness in the flanks? In the absence of 
diarrhea there is every reason to believe that this sign indicates fluid free 
in the peritoneal cavity, but this is fully as common in cases of intestinal 
obstruction as in general perforative peritonitis. 

Many of the symptoms here present could be explained by simple 
constipation. Indeed, on paper this seems quite a reasonable diagnosis. 
In the living patient, however, this could be quite readily excluded by 
the obvious severity of the patient's sufferings and of the prostration 
accompanying them. By the same tokens it was easily possible to rule 
out those multiform neuroses which are, on the whole, the commonest 
cause of general abdominal pain. 

By exclusion, intestinal obstruction seems the most probable diag- 
nosis. 

Outcome. — The abdomen was opened at once, and the mesentery 
of the lower ilium was found to be tightly twisted on itself, the twist 
leading to a group of intestinal coils which were distended and dark 
purple in color. There were many adhesions near the site of the appen- 
dix, but apparently these were not responsible in any direct way for the 
strangulation. There was about a quart of bloody serum free in the 
abdomen. 

The intestines were untwisted and returned to their proper position, 
the wound sewed up, and the patient made an uneventful recovery, 

This case illustrates the truth of the rule that in young people most 
cases of intestinal obstruction are connected in some way with the 
results of a previous peritonitis or operation, while in old people the great 
majority of cases are due to cancer. For some unknown reason twists 
occur much more frequently in those whose peritoneums have been 
damaged by a previous operation or inflammation, even when no con- 
stricting band of adhesions can be found. 

Diagnosis. — Obstruction of the intestine; volvulus. 



GENERAL ABDOMINAL PAIN 



153 





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CHAPTER V 

EPIGASTRIC PAIN 
Case 66 

An Italian laborer of forty entered the hospital November 22, 1906. 
For sixteen days he had been having pain at the "pit of the stomach." 
The pain came on rather suddenly, and had since been dull and steady, 
at times interfering with sleep. He has not been able to work since the 
onset of the pain. It has no relation to food or posture. There are no 
gastric or urinary symptoms, no jaundice, no constipation, and no loss 
of weight. The patient denies venereal disease, and has never, to his 
knowledge, been sick before. 

Physical examination, except in so far as relates to the abdomen, 
was negative. There a hard, apparently nodular mass was felt just 
below the ensiform cartilage and a little to the left of the median line. 
It was not tender, and descended readily with inspiration. The liver 
dulness extended as high as the fourth interspace, but the edge was not 
felt. The blood and urine showed nothing abnormal. The capacity 
of the stomach was enlarged to 72 ounces, and the lower border reached 
4-J inches below the navel; the upper border, 1 inch above it. Free HC1 
was absent. The total acidity was 0.12 per cent. There were no 
organic acids, no blood, no fasting contents. There was no reaction to 
guaiac in the stools. The patient's temperature ranged, for the most 
part, about 99 ° F., often reaching ioo° F. and occasionally 101 F. His 
pulse and respiration were within normal limits. At times there was 
considerable tenderness over the epigastric mass. 

Discussion. — Tuberculous peritonitis is remarkably common in the 
newly arrived Italian immigrant. The presence of fever and of ab- 
dominal pain without fulminating or alarming symptoms is quite sug- 
gestive of tuberculous peritonitis, but we have no evidence either of free 
fluid in the abdomen or of the tenderness, spasticity, and localized 
masses which are necessary for the diagnosis of this disease when fluid 
is absent. 

Some of the gastric signs in this case are quite consistent with gastric 
cancer, but against this are the sudden onset, the absence of emaciation, 
stasis, or blood. 
1 54 



Causes of Epigastric Pain 



CONSTIPATION 

DIARRHEA AND ENTERITIS 

ACUTE INDIGESTION 

APPENDICITIS 

NEUROSES 

LEAD-POISONING 

INTESTINAL OBSTRUCTION 

TABES 

TABES PERITONITIS AND TABES MESENTERICA 



NO ACCURATE STATISTICS' 
AVAILABLE. 
• ONLY THE FIRST THREE ARE 
COMMON AS CAUSES OF EPI- 
GASTRIC PAIN. 



I. GASTROHEPATIC 
CONGESTION 
DUE TO C I R- 
RHOSIS OR CAR- 
DIAC DISEASE 



898 



2. APPENDICITIS 

3. PEPTIC ULCER 

4. GALL-STONES 

5. HYPERCHLOR-) 

HYDRIA 1 J 

6. GASTRIC CANCER I 

7. PERICARDITIS ■ 

8. GASTRIC NEUROSIS ■ 

9. PANCREATITIS I 



350 
347 
329 

326 

133 
88 
72 

7 



10. PYLORIC i 

ADHESIONS I 

11. ANGINA ABDOMI- 

NALIS 



1 M.inv of these ci dually !><■ cases of peptic ulcer. Only operation or 

■atop ide. 



-*4T 












n 






r 






c* 






EPIGASTRIC PAIN 



157 



The induration about a partially perforated gastric ulcer sometimes 
produces a mass in the left hypochondrium similar to that here described. 
But as the symptoms seem to have no relation to food, and as there is 
no tenderness or spasm about the indurated point, there seems to be 
no good reason to consider this possibility seriously. 

The tumor is on the wrong side for gall-bladder disease, and the 
absence of colic and jaundice makes it unnecessary to look further in this 
direction. 

Malignant disease of the liver might cause such a fever as is here 
described, and occasionally arises without any previous or coincident 
growth in the stomach. This possibility cannot be excluded, especially 
as the liver seems to be enlarged upward; but the left hypochondrium 
is a very unusual place for a hepatic neoplasm. 

On the other hand, the position of the mass here described corre- 
sponds with the point at which hepatic syphilis most often shows itself. 
This diagnosis would explain the fever, and is more consistent with the 
history and with the good nutrition of the patient. In the absence of 
any further evidence, however, one could not do more than suspect 
syphilis. Treatment by mercury and potassium iodid and the use of the 
Wassermann test are indicated as a means to a more certain diagnosis. 

Outcome. — On December 6th the abdomen was opened, and the 
liver was found to be adherent to the abdominal wall by fine, soft ad- 
hesions. The mass felt through the abdominal wall was found to consist 
of an irregular, boggy, yellowish-white elevation, from which a con- 
siderable amount of pus-like material was removed by cautery. 

Microscopic examination showed it to be a gumma. The patient 
left the hospital on December 29th feeling perfectly well. 

Diagnosis. — Hepatic gumma; syphilis. 

Case 67 

A Lithuanian of twenty-nine, working in a rubber factory, and 
never consciously sick in his life before, entered the hospital April 10, 
1907. Sometimes Ik- takes as much as eight beers and four whiskies 
daily. At other times he goes without alcohol for at least a week. 

For two weeks he had been having severe epigastric pain, with loss (A 
appetite and obstinate constipation. 

The patient was very nervous, trembling, and pale. The red cells 

-0,000; hemoglobin, 65 per cent.; white cells, yjoo. The 
stained smear showed 78 per cent, of polynuclear cells and very 
marked stippling of the red-. The abdomen was flat, moderately stiff, 

lightly tender. The reflexes '.'.ere \ ei y Lively, and there was hyper- 



158 DIFFERENTIAL DIAGNOSIS 

esthesia of the feet. The aortic second sound was accentuated. The 
urine showed a very slight trace of albumin; otherwise it was negative, 
as was the rest of the physical examination. 

Three days after entrance the patient became maniacal in the night 
and had to be restrained. This continued for six days, after which he 
became sane. His temperature was frequently above 99 ° F., and once 
reached 101.4 F. This was at the height of his maniacal attack. 

Discussion. — The history, the maniacal attack, and the gastric 
symptoms point toward alcoholism. The anemia, however, is not 
thus to be explained. 

Tuberculous peritonitis and meningitis are suggested by the com- 
bination of a spastic, tender abdominal wall, and the maniacal attack 
accompanied by fever. This form of tuberculosis, however, rarely 
produces anemia, and mania is very unlikely in it, unless other cerebral 
symptoms (lethargy, coma, squints, headache, or vomiting) are also 
present. 

Work in a rubber factory often produces a stubborn type of general 
debility, but it does not lead, so far as I know, to fever, to mania, or to 
anything like this grave anemia. 

Nephritis must be considered. It would explain the albuminuria, 
the accentuated aortic second sound, and the mania; but a nephritis 
which had lasted long enough to produce such an anemia would almost 
certainly produce a demonstrable enlargement of the heart and some 
other uremic manifestations, such as headache, vomiting, or hemor- 
rhages. 

Lead-poisoning should always be considered in a case presenting 
the combination of anemia and cerebral symptoms, especially if the red 
cells contain a basophilic granulation, as in this case. Looked at from 
this point of view, all the symptoms seem to fall very naturally into line — 
lead colic, lead anemia, lead nephritis, lead encephalopathy. 

Outcome. — The treatment consisted at the beginning of glycerin 
enemata and magnesium sulphate, with morphin for the pain. Iodid 
of potash, 10 grains, was given three times a day, while hot applica- 
tions and turpentine stupes were also used for the. pain. Chloroform 
anesthesia was once needed during his attack of mania. Fifteen grains 
of trional were given several times for sleep. 

April 19th the red cells were 3,600,000, and no stippling was found. 

By the twenty-third of April he had nearly recovered and was ready 
to go home. It was subsequently found that he drank water which came 
through a lead pipe, and that he seldom let the water run before drinking 
in the morning. 



EPIGASTRIC PAIN 



159 



In connection with this case I will mention briefly a patient to whom 
I was called because of anemia and convulsive attacks. She was a young 
married woman with a baby three months old. She lived in a rural 
district, and did no work outside her own house. Epilepsy and uremia 
were the diagnoses previously considered, but examination showed 
that she and every other member of the household except the baby had 
a well-marked lead-line on the gum and all the other evidences of lead- 
poisoning. After giving up a water-supply heavily impregnated with 
lead, this patient rapidly recovered. 

Diagnosis. — Plumbism. 

Case 68 

A blacksmith of twenty-three entered the hospital November 24, 
1906, with a negative family history and past history and good habits. 
He had been complaining for three weeks of epigastric pain, usually 
coming on about eleven o'clock in the morning, seeming to bear no rela- 
tion to food — described as "pulling" in character, and relieved by lying 
down. There had been slight tenderness in the epigastrium, especially 
under the right ribs. The bowels had been very constipated, moving 
only once in three days. Three days ago he began to vomit, and had 
done so once or twice a day since. The vomitus contained no blood 
or food, but was yellow in color. His pain was never present when he 
waked in the morning; it was sometimes brought on by drinking water. 
He appeared to be 15 pounds lighter than in the previous June. 

Physical examination was entirely negative, except that lumps were 
felt in the sigmoid region. 

Discussion. — It does not seem likely that a blacksmith of twenty- 
three is suffering from a pure neurosis, and he is at an age when cancer of 
the stomach is very rare. The pain comes at a time when the stomach 
is likely to be empty, and, therefore, suggests hvperchlorhydria or duo- 
denal ulcer. The fact that his vomitus contains no food goes to strengthen 
this hypothesis, and the negative physical examination is entirely con- 
si-tent with it. 

1- it possible that the lumps felt in the sigmoid region may be due to 
,1 accumulation behind a stricture, cancerous or of other origin? 

1 have known cancer of the intestine in a boy <>f twenty-one, so that the 

of this patient does not exclude thai possibility, and the vomiting 
and constipation are quite consistent with it. In the absence <>f more 
definite symptom-, however Such as visible peristalsis, blood in the 

. and abdominal distention), there seems to be nothing further to 

verify this id. 



!6o DIFFERENTIAL DIAGNOSIS 

May not the symptoms be due to simple constipation, so called? 
Why then should he have symptoms just now and not previously? 

On the whole, the youth of the patient and the short duration of the 
symptoms make cancer and constipation less likely than the other al- 
ternative above mentioned, but no certainty can be attained on the basis 
of the facts here presented. Only by the therapeutic test — the results of 
treating the patient for duodenal ulcer (a treatment identical, in its 
early stages, with that of hyperchlorhydria) — can greater certainty be 
obtained. 

Outcome. — After castor oil by mouth and enemata of oil, large 
movements followed. Guaiac test negative. Olive oil by mouth also 
relieved him very much, likewise a gastric ulcer diet. In five days he 
seemed to be entirely well. 

Diagnosis. — Constipation. 

Case 69 

A chambermaid of twenty-two, with a negative previous history 
and family history, entered the hospital March 2, 1907. In February, 
1906, she had what was called "grip," followed by abdominal pain, 
weakness, and the loss of 10 pounds in weight. The pain was sudden 
and nagging, coming sometimes immediately after meals, sometimes 
later, never lasting long, and never severe. She has had recurrences 
of this pain at intervals ever since. Four weeks ago the pain became 
more troublesome, and was accompanied by belching and constipation. 
It did not always remain in the epigastrium, but might shift to the lower 
abdomen, to the left chest, and to the back. It seemed to be produced 
especially by toast, potatoes, and meat; it was sometimes relieved by 
drinking hot water, but not by cooking-soda. It had kept her awake 
during the past two nights. She also complained of "palpitation in her 
stomach." She had very rarely vomited. At the present time her 
bowels are regular, and she feels fairly well except for weakness. 

On physical examination it was noted that her cheeks were red, but 
her lips pale. The chest, abdomen, and urine showed nothing remark- 
able. Blood examination showed: Red cells, 4,976,000; white cells, 
5600; hemoglobin, 60 per cent. The stained specimen was normal 
except for moderate achromia. The patient was treated by a careful 
diet. 

Discussion. — Lead-poisoning is always one of the possibilities 
when a patient demonstrably anemic complains of abdominal pain. 
Lead may be excluded, however, in my opinion, by the absence of baso- 
philic stippling in the red cells. I have never known a clear case of 



EPIGASTRIC PAIN l6l 

plumbism without stippling: There was nothing else, moreover, to 
favor the suspicion of lead-poisoning in this patient. 

If the patient were somewhat older, the history would be quite con- 
sistent with gastric cancer, which would also explain the anemia ; but as 
these symptoms have lasted a year, we should almost certainly find more 
evidence of cancer if that were the cause of the patient's sufferings. 

Chlorosis is generally accompanied by constipation and hyper- 
chlorhydria, which appear to be present in this case. The age and the 
occupation favor this diagnosis, which may be provisionally accepted, 
subject to confirmation by the results of treatment. The pain in this 
case is very typical of that most often associated with constipation, 
whether or not the latter is its cause. 

Outcome. — The bowels were regulated by cascara and enemata. 
She was given 10 grains of B laud's pill after each meal. Recovery 
was uneventful. 

Diagnosis. — Chlorosis. 

Case 70 

A married woman of thirty-five entered the hospital December 5, 
1906. She has always been well, but subject to what she calls bilious 
attacks. She was operated on four years ago for strangulated hernia . 
Since then she has had a great deal of severe, cramp-like epigastric 
pain, sometimes relieved by a movement of the bowels. On December 
10, 1905, the catamenia failed to appear, and she had vomiting and 
headache. In January, 1906, she was operated on for extra-uterine 
pregnancy. In convalescence she was troubled by diarrhea and gaseous 
distention of the bowels. Later on she was obstinately constipated. 
She felt as if her intestines would fall out, but found relief by holding 
them up with her hands. Two months ago she woke up with a violent 
pain in her right hand. The next morning the hand was swollen up so 
that she could not close it. This trouble soon passed away, but ever 
since that time, she says, she never knew when a sharp, shooting pain 
would strike her. The pains were felt in all parts of the body, and lasted 
from a minute to four hours. She has had to take morphin for them at 
times. She says that she had never been nervous or hysteric before. 
She now enters the hospital expecting an operation for intestinal obstruc- 
tion, having been sent in by one of the visiting surgeons with a diagnosis 
of intestinal obstruction of mechanical origin. 

Physical examination showed that the pupils wen" irregular and did 
not read to light. Knee jerks were present, but diminished. The 
ankle jerk was absent; Otherwise examination of the reflexes was negative. 



1 62 DIFFERENTIAL DIAGNOSIS 

Sensation and coordination appeared to be perfect. In the right loin a 
mass was felt descending below the ribs on deep inspiration, slightly 
tender. 

Physical examination, including the blood and urine, was otherwise 
negative. 

Discussion. — Certainly a very complicated case. No doubt con- 
stipation accounts for a part of the symptoms, but the pains are very 
wide-spread and unusually intense for constipation. Moreover, there 
are certain facts in the physical examination which cannot possibly be 
thus explained. 

Intestinal obstruction by bands or adhesions is always a menace in 
those who have had a strangulated hernia and an operation for extra- 
uterine pregnancy; but for the same reason as mentioned in the last para- 
graph, intestinal obstruction cannot account for all the facts in this case. 

Much in the patient's behavior and appearance, and something in 
her symptoms, point toward a neurosis, but this would not account for 
the absence of ankle-jerks and pupillary reactions. 

The signs just mentioned practically assure us that this patient has 
tabes dorsalis. The only important question remaining is whether the 
tabes explains all the symptoms. Certainly the pains are very character- 
istic of tabes, and the gastro-intestinal symptoms may well be inter- 
preted as "crises." The mass in the loin is certainly not due to tabes, 
but in all probability does not represent evidence of any disease what- 
ever, but is merely a sagging kidney. 

On the whole, it seems reasonable to believe that all the symptoms 
are now due to tabes. At any rate, the patient should be treated on that 
basis for the present. The chief lesson of the case is the necessity for 
self-restraint on the part of earnest surgeons when the patient's pupils 
and Achilles tendons fail to react. 

Outcome. — The patient remained only two days in the hospital, 
whither she had come reluctantly and under the impression that a 
second operation would be necessary. When it was decided that no 
operation was advisable, she declared that she felt well and went home at 
once. 

Diagnosis. — Tabes dorsalis. 

Case 71 

A married woman of forty-two, of negative family history and past 
history, entered the hospital December i, 1906. On January 28, 1906, 
she broke her leg and was confined to bed for eight weeks, during which 
time she lost her appetite, had palpitation of the heart, a grinding pain 



EPIGASTRIC PAIN ^3 

in the epigastrium, and a feeling as if there were strings inside her 
hitched to the navel and to the backbone. She had occasional vomiting 
of whitish material. She was given various medicaments without relief. 
In July she began to walk on crutches, but her symptoms were unrelieved. 
Her appetite was poor, and she lost 30 pounds in weight between Janu- 
ary and December. 

Her physical examination was entirely negative, except for a leuko- 
cytosis of 20,000. The gastric capacity was 27 ounces; the stomach 
considerably prolapsed. There were no fasting contents, and after a 
test-meal free hydrochloric acid was found to the amount of 0.23 per 
cent. There was no blood. Three days later the white cells had fallen 
to 10,000, and ranged between that and 16,000 during the three weeks of 
her stay in the hospital. At no time was there anything abnormal about 
her temperature, pulse, or respiration. 

Discussion. — It is natural to fear cancer in this case, for gastric 
symptoms of recent origin always threaten cancer when the patient is 
over forty. The presence of abundant free hydrochloric acid in the 
stomach-contents by no means excludes cancer. The most hopeful 
feature in this regard is the absence of tumor or stasis, one of which 
would, in all probability, be manifest after a year of suffering. 

To those who are always on the look-out for psychic causes in gastro- 
intestinal disease, the fact that this patient had no stomach trouble until 
she broke her leg and was confined to bed, offers an important clue. It 
should lead us to investigate very carefully the patient's mental condition. 

Outcome. — It turned put on careful questioning that she feared she 
was suffering from cancer. She was greatly encouraged by the negative 
results of the gastric tests, and in eighteen days gained 7 J pounds, mostly 
as a result of forced feeding, with laxatives and myrrh pill, one or two at 
night, aromatic chalk mixture, sodium bicarbonate when in distress, 
and a quassia cup before meals. She was also relieved by 10 grains 
of sodium bromid after meals, and on two or three occasions had trional 
at night. The main point, however, in her recovery, was forced feeding. 

The leukocytosis is not explained, but must be listed as one of those 
wild and untamed facts which T have grown to expect as a normal 
element in every well studied case. 

Diagnosis. —Gastric neurosis. 

Case 72 

A factory hand of thirty-eight entered the hospital December 
1007. Seven years ago he began to suffer from tape-worm, of which 

ments were passed until three years ag< whole worm 



3:64 DIFFERENTIAL DIAGNOSIS 

was removed. During this time he had attacks of epigastric pain and 
vomiting, often associated with jaundice. His family history and habits 
are good. Eight days ago he was again seized with pain in the epi- 
gastrium, relieved by vomiting. An hour later the pain returned and he 
vomited again. This happened five times that day. The next day he 
kept quiet and had no pain or vomiting. On the third day he went to 
work, and the pain and vomiting recurred. On the fourth day he was 
quiet and felt well. On the fifth day he again worked, and again had 
pain and vomiting. For the past three days he has not worked and has 
felt well. This association of pain with work has been present in all his 
past attacks. He has never had pain at night, on Sundays, or on holi- 
days; and during the time that he has had these attacks he has changed 
his work three times. His pain bears no special relation to the time or 
kind of food. The vomitus consists of small amounts of greenish mater- 
ial and saliva. He has never seen food or blood either in the vomitus 
or in his stools. During the attacks his appetite is poor and his bowels 
constipated. He states that he has been considerably jaundiced during 
this last attack. He has lost five pounds in the course of the last year. 

On physical examination no jaundice is found. Many teeth are 
missing; the rest are in fair condition. There is a systolic murmur 
at the apex, not transmitted. The heart-apex is in the fifth interspace, 
inside the nipple-line. The aortic second sound is louder than the 
pulmonic second sound. The tension of the pulse is apparently high, 
the lungs normal. The abdomen is level, slightly rigid, tympanitic 
throughout, and very slightly tender on pressure in the epigastrium. 
There are slight dulness and resistance in the region of the gall-bladder, 
but no jaundice. The liver is not felt. Physical examination, includ- 
ing the blood and urine, is otherwise normal. 

Discussion. — The tape- worm is obviously "a blind." It is very 
unlikely that the epigastric pain and vomiting from which the patient 
suffered from 1900 to 1904 had any real connection with the tape-worm. 
It is perhaps worth mentioning here that practically all the symptoms 
traditionally associated with tape-worm are mythical. In the vast 
majority of cases tape-worm produces no symptoms whatever. 

Since the death and burial of "gastralgia," that ancient foe of clear 
diagnosis and helpful treatment, such pain as this patient suffered has 
been shown to be generally due to one of two causes — duodenal ulcer or 
gall-stones. Since the attacks have apparently been associated with 
jaundice, our first thought is gall-stones, but on a closer study of the 
case we find that he has now no jaundice, although he now considers 
himself as yellow as in the previous attacks. This makes us doubt 



EPIGASTRIC PAIN jfr^ 

whether he really was ever jaundiced. I have many times found reason 
to discount patient's own statements in this matter. Patients and their 
friends often use the word "jaundice" to denote nothing more definite 
than a sallow complexion. To the consideration of duodenal ulcer I 
shall return later. 

Aneurysm or angina abdominalis is suggested by the fact that the 
pain is increased by exertion and the pulse tension high. On the other 
hand, a pain which produces and is relieved by vomiting is rarely due to 
either of the causes just mentioned. The physical examination shows 
no evidence of aneurysm. 

Is it likely that the lack of a good set of teeth explains some or all of 
this patient's symptoms? It does not seem to me so. Despite the many 
positive statements regarding the close association of digestive troubles 
and poor or deficient teeth, I have never seen any clinical evidence 
which would enable us to say more than "perhaps," so extraordinarily 
common is it to examine people who have lived their lives quite free from 
digestive troubles, though only one or two blackened fangs remain in each 
jaw. I by no means deny the possibility that malnutrition or poor diges- 
tion may in certain cases be due to defective teeth, but I think we need 
a great deal more definite study and evidence before we shall have 
justification for the positive statements and the expensive municipal 
crusades that are now so rife. 

A definite diagnosis in this case would be easier if we knew — (a) 
Whether there is blood in the stools and (b) w T hether hyperchlorhydria 
is present. Even in the absence, however, of these data I think the 
diagnosis of duodenal ulcer is justifiable. Between this disease and the 
hyperchlorhydria which leads to it diagnosis is not always possible, as 
will be exemplified in a subsequent case. The absence of any tem- 
peramental or occupational cause for the worry and irritability so often 
associated with hyperchlorhydria makes me incline, on the whole, 
toward ulcer. 

Outcome. — On January i, 1908, the abdomen was opened. The 
gall-bladder and ducts were found to be normal, but a small duodenal 
ulcer was present. No aneurysm. The patient made a good recovery. 

Diagnosis. — Duodenal ulcer. 

Case 73 

A married woman of forty seven, with negative family history and 

good habits, entered the hospital December 21, IQ07. She stated that 

for eighteen years she has had abdominal cramps every three or four 

months, but that for the last two weeks these have come much more 



x 66 DIFFERENTIAL DIAGNOSIS 

often — seven times in two weeks. The pain starts in the epigastrium 
very suddenly and without known cause, without relation to food, 
to menstruation, or to the time of day. It radiates to the right flank, 
lasts about three hours, and often wakes her from sleep. It is usually 
accompanied by vomiting of food or brownish liquid. There is no his- 
tory of jaundice, and between attacks she feels perfectly well, although 
the pain is so severe as to require morphin. Her bowels are regular, 
her urination normal, although for the last three days she has passed less 
urine than usual. She thinks she has lost a great deal of weight. 

Physical examination is negative, except for considerable epigastric 
tenderness. The white cells number 15,800; the stained smear negative. 
The urine contains a slight trace of albumin; gravity, 1030; a few hyaline 
and granular casts. 

Discussion. — Such symptoms might be due to constipation, but her 
negative statement upon this point was confirmed by our observation in 
the hospital. The history is also suggestive of lead-poisoning, except 
for its extreme duration, but the condition of the blood and of the gums 
enables us to rule this out. 

The negative physical examination, which included tests of the 
pupillary and other important reflexes, makes tabes with gastric crisis 
out of the question. The regularity of the bowels and the long dura- 
tion of symptoms render chronic intestinal obstruction (cancer) very 
unlikely. 

Gastric cancer is always to be feared at the age of forty-seven when 
the patient has vomited a brownish liquid at frequent intervals, has had a 
great deal of epigastric pain, and is believed to have lost a great deal of 
weight. By the use of the stomach-tube we were able to establish the 
fact that there were no gastric stasis and no blood in the stomach-con- 
tents or in the vomitus. The size of the stomach was normal, and no 
tumor palpable. 

Duodenal ulcer often gives a history of very prolonged suffering, 
similar to that in this case, and there is nothing in the history to exclude 
it. Even the fact that blood was absent from the vomitus, the artificially 
abstracted gastric contents, and the feces by no means excludes ulcer. 
The radiation of the pain, however, its sudden onset and its sudden 
relief by morphin, are less characteristic of duodenal ulcer than of the 
disease next to be considered. We note also the absence of any relation 
between the pain and the digestive activities. 

Gall-stones might explain all the symptoms in the case, although the 
diagnosis is not forced upon our notice, as it would be were jaundice 
present. We are no longer surprised, however, to find gall-stones in the 



EPIGASTRIC PAIN ^7 

absence of jaundice, and, on the whole, no other diagnosis seems as 
likely. The negative physical examination does not militate at all 
against this idea, nor does the condition of the urine incline us to change 
our minds, though it is not at all obvious why the albumin and casts are 
present. 

Outcome. — On December 26, 1907, the abdomen was opened and 
15 large stones were found in the gall-bladder. The patient made a 
good recovery. 

Diagnosis. — Gall-stones. 

Case 74 

A tailor of forty-nine with a good family history and good habits 
entered the hospital on June 15, 1907. For the last eighteen years he 
has had occasional spells of dull epigastric pain coming on in the after- 
noon for a month or so. These attacks had never troubled him much, 
and were often absent for a month at a time; but for the last ten years 
they have become more frequent, and the pain has appeared in the 
morning, as well as in the afternoon, accompanied by a feeling of weight 
in the abdomen, but rarely by vomiting. About a year ago the pain 
began to come regularly between 10 and 12 in the morning, and between 
4 and 6 in the afternoon, except during the periods when he was under 
treatment. The pain is now sharp, and radiates sometimes from the 
epigastrium to the back, rarely to the left hypochondrium. It is partly 
relieved by eating, and wholly by cooking-soda, but never by pressure. 
He frequently belches gas. 

Two months ago, after a day during which he had been constantly 
regurgitating sour fluid, he vomited at one time almost three quarts of 
sour, foaming yellow fluid, with great relief. Two weeks ago he vomited 
a similar quantity, and at the end of it was a little chocolate-colored 
stuff. He thinks he has lost 20 pounds in the last six months, yet he 
worked until May 29th and until very recently felt as strong as ever, 
and has eaten and slept well. 

Physical examination was negative, except that the stomach capacity 
was 74 ounces, the organ extending three inches below the navel and 
showing visible peristalsis. 

Discussion. — Here is a history nearly typical of duodenal ulcer. 
1 have given i! here to prove that in some such cases no ulcer is demon- 
strable at operation. One of the wisest clinicians of my acquaintance 
'ly said in a personal letter: " In mv experience ' hvpcrchlorh\<lri;i ' 

illy spells duodenal ulcer. 1 ' I agree with this statement if it is 

literally that is, if we distinguish "generally" from "always." 



1 68 DIFFERENTIAL DIAGNOSIS 

My object at the present time is to exemplify one of the weak points in 
clinical diagnosis — our inability, namely, clearly to distinguish the two 
diseases above referred to. Had we known at the outset that this patient 
was an alcoholic, the balance might have inclined a little more toward 
hyperchlorhydria, as this trouble is not infrequently associated with 
alcoholism. But still we should have been wandering in the region of 
probabilities. 

Outcome. — Operation on the ninth of July showed no dilatation, 
ulceration, or scar formation anywhere in the stomach or duodenum. 
The pyloric ring was of good size. The patient made a good recovery, 
and on July 28, 1908, reports that he had had similar attacks of pain, 
but less severe. He now admits that at times he drinks liquor freely, 
but thinks that these sprees have no relation to his gastric attacks. 

Diagnosis. — Hyperchlorhydria (alcoholism?) . 

Case 75 

A farmer of forty-six, with a negative family history and good habits, 
entered the hospital February 19, 1907. For the past two years he has 
had many severe attacks of epigastric pain, coming without apparent 
cause, and relieved about once a month by vomiting. For the past two 
weeks the pain has increased in severity. He localizes it accurately 
just below the ensiform cartilage, and describes it as sharp, increased 
by coughing, by exertion, or by a meal containing pork, eggs, or veal. 
It is usually worse at night, especially just after he goes to bed. It is 
somewhat relieved by hot- water bottles, but it generally keeps him awake 
most of the night. 

Physical examination shows the heart's impulse two inches outside 
the nipple-line in the fifth space. There is a presystolic thrill and 
murmur at the apex, ending in a sharp first sound. A short systolic 
murmur is also heard at the apex. Both murmurs are transmitted to 
the axilla. The pulmonic second sound is very difficult to hear. At 
the base of the heart a soft systolic thrill can be felt in the aortic area, 
and a high-pitched diastolic murmur heard under the sternum at the 
level of the third rib and above this point, together with a soft systolic 
murmur, which is audible throughout the precordia. No second sound 
can be heard in the aortic region. The pulse is of the plateau type; 
the arteries are tortuous and thickened. There is a lateral excursion 
of the brachials. Blood-pressure, 195. The edge of the liver is felt on 
inspiration, and there is moderate tenderness, sharply localized below 
the ensiform cartilage, and accompanied by muscular spasm. 

Discussion. — In this case, as in most of those preceding and follow- 



EPIGASTRIC PAIN 1 69 

ing it, the pain is worse at night. This symptom has often been referred 
to as characteristic of gall-stone pain or duodenal ulcer, and there are 
other features in the case consistent with one of those two diagnoses, 
but it is of crucial importance in the study of this case to note that the 
pain is increased by exertion and by coughing. This is not usually 
the case with duodenal ulcer or gall-stones, although inflammatory 
adhesions may be so situated that muscular action stretches them pain- 
fully. 

The presence of the well-marked heart lesions (aortic stenosis and 
regurgitation), and especially of the high blood-pressure, makes us 
suspect any pain of being connected with the circulatory system. The 
relation to exertion is very characteristic of angina pectoris. Does pain 
of this type ever occur as low as the epigastrium? It certainly does, 
although the term "angina abdominalis" is perhaps more appropriate. 
I have seen a great many cases of this type treated quite unsuccessfully 
by stomach specialists without regard to the circulatory condition. 
To get further clearness on the diagnosis, one would need to observe 
carefully the effect of rest and of nitroglycerin. Certainly no type of 
stomach or gall-bladder trouble is relieved by nitroglycerin. 

Outcome. — A few days' observation in the hospital ward demon- 
strated the truth of our suspicions: rest rendered the attacks less fre- 
quent, and those which occurred were promptly relieved by nitroglycerin. 

Diagnosis. — Angina pectoris (low). 

Case 76 

A salesman of forty-nine came to the hospital on December 10, 1907, 
complaining of pain, constipation, and vomiting. He is in the habit of 
taking several drinks of whisky a day, but has never been sick until the 
present illness, and his family history is good. For five weeks lie has 
suffered from abdominal pain. The pain began at a time when he was 
"not feeling well," and had stopped work for a few days. It is in the 
epigastrium, worse at night, relieved by eating, and accompanied In- 
much wind and belching. It usually begins about 4 P. m., and reaches 
its maximum severity between 11 P. M. and 4 A. M., after which it sub- 
Of late it has come every night. He often vomits with the pain, 
and last Ilight did so three times. He has small movements of the 

ery second or third day. Two months ago he weighed 1O0 
pounds. Now he weighs 136 pounds. 

Physical examination, including the urine, is negative. No lead- 
line is to he seen. The leukocytes number 10,400; hemoglobin, 00 

per ( int. In the differentia] ( OUnt the polynuclear cells are So per cent.; 



170 DIFFERENTIAL DIAGNOSIS 

lymphocytes, 18 per cent. ; eosinophiles, 2 per cent. There is very marked 
stippling and abnormal staining of many red cells. 

Three days later the urine was found to contain a trace of albumin, 
with numerous hyaline, finely and coarsely granular casts, many with 
cells adherent. 

Discussion. — Our first impression is naturally that "rum done it," 
but on second thought there seems no special reason why he should 
suddenly begin to suffer at this time as the result of so long continued 
a habit. 

The fact that his bowels are so constipated raises the question 
whether this trouble may not account for all his symptoms, whether it 
be of the ordinary functional type or dependent upon a stricture (malig- 
nant?). But, as before, the question arises, why should he suddenly 
begin to suffer from constipation at the age of forty-nine? The func- 
tional types of the affection usually make their appearance long before 
that age. Only some special aberration in diet or some great nervous 
strain would account for the sudden appearance of functional constipa- 
tion in a man of this age. 

It is possible, of course, as I have previously stated, that cancer of 
the bowel may exist for months or even years without manifesting its 
presence by any symptoms, but when we look over the history and ex- 
amine the patient with this possibility in mind, there seems to be nothing 
to support it, although the loss of weight is suggestive. 

A pain relieved by eating often occurs in connection with hyperchlor- 
hydria or peptic ulcer, and there is nothing in the case absolutely to 
exclude these affections, which, like cholelithiasis, must always remain 
in the background of our minds when paroxysmal epigastric pain is the 
presenting symptom. 

Before making any further investigation or following up any other 
clue, we should test the possibilities suggested by the presence of marked 
stippling in the stained red corpuscles despite the absence of anemia. 
Although no lead line is seen and nothing in the patient's occupation 
suggests plumbism, this blood lesion is so characteristic that every 
effort should be made to follow it as a clue. 

Outcome. — During the first three days the diagnosis was not made; 
and later it was discovered that he has for three years used drinking- 
water coming through 30 feet of lead pipe. His blood-pressure was found 
to be 185 mm. 

On December 17th his attacks of colic were less marked, but sudden 
muscular weakness in both arms appeared for the first time. On Decem- 
ber 24th he was free from colic and the urine had cleared up, but the arms 



EPIGASTRIC PAIN 171 

and back showed very marked muscular weakness. On this day 
(the 24th) a well-marked lead line was found on the gums, visible only on 
the inner side of the teeth of the lower jaw. 
Diagnosis. — Plumbism. 

Case 77 

A negro of sixty-four entered the hospital August 7, 1907. He 
stated that his mother died at eighty-five "of worry." His family his- 
tory is otherwise not remarkable. He now complains of severe epigastric 
pain which had been present for three months. During the Civil War 
he drank a quart of whisky daily. Fifteen years ago he had a venereal 
sore which was treated at the Boston Dispensary with calomel locally 
and iodid of potassium internally. He was treated for six months and 
noticed no secondary symptoms. He says it was his habit to take three or 
four glasses of whisky a day and three or four beers, but for the past 
four months he has abstained. He smokes and chews five cents' worth 
of tobacco a day. 

At the onset of the pain, three months before, he fell in the street, 
although he was not unconscious. Since that time the pain is apt to 
radiate from the epigastrium across his chest or up his left side and 
through his back. Occasionally it shoots from the lower part of his back 
up to his left shoulder, or from his right hip down his leg, but it is worst in 
the epigastrium. 

Four weeks ago he was examined at the Boston Dispensary and 
thinks that he was ruptured at that time. He has had no vomiting, head- 
ache, or palpitation. In January, 1907, he weighed 180 pounds; in June, 
145 pounds; now, 140. His digestion is good. 

Physical examination shows a pallor of the mucous membranes. The 
heart is negative except for accentuation of the aortic second sound. 
The carotid arteries are prominent and easily palpable. The blood- 
pressure is 130 mm. of mercury. The right lung shows a consider- 
able number of coarse rales below the scapula, with moderate dulness 
extending to the base of the lung. One and a half inches below the right 
costal margin is a rounded nodule an inch and a half in diameter, con- 
siderably elevated, apparently not connected with the skin. It is some- 
what movable, not tender, and docs not descend with respiration. There 
is dulness in both flanks, shifting with change of position. The penis is 
six inches in circumference, markedly edematous, as is the perineum. 
notions of the back are limited and painful. A rectal examination 
I that the prostate LS the size of a small grape-fruit, very firm, im- 



172 DIFFERENTIAL DIAGNOSIS 

movable in the pelvis, and encroaching markedly upon the rectum. 
The right testis is enlarged and tender. 

Red cells, 2,696,000; differential count normal; white cells, 14,200; 
hemoglobin, 45 per cent. 

Discussion. — Abdominal aneurysm must certainly be considered as 
a cause of pain like that described in this case, especially when there 
is so well authenticated a history of syphilitic infection. The enlarged 
testicle would then naturally be explained as syphilitic orchitis. The 
sudden onset of the pain and its prostrating effects might be accounted 
for by a partial rupture of the aneurysmal sac. 

Against this diagnosis, however, is the evidence furnished by rectal 
examination. I know of no syphilitic lesion which will produce such 
changes in the prostate. Another fact of importance, which came to 
light later, was the inefficiency of a prolonged course of antisyphilitic 
treatment which he had recently undergone. Malignant disease is 
certainly the commonest cause for an extensive, hard, immovable tumor 
connected with the prostate gland. This would easily account for the 
anemia and for the nodule in the abdominal wall, though both of these 
might possibly be accounted for also by syphilis. 

If malignant disease is the correct diagnosis, why was the patient so 
suddenly stricken that he fell in the street three months before? I can 
give no confident answer to this question. Possibly his habits have some- 
thing to do with explaining it. 

Outcome. — The patient died on the tenth of August. Autopsy showed 
sarcoma of the right testis, with metastasis in the prostate, adrenal glands, 
small intestine, bronchial lymphatic glands, pleura, pericardium, and 
abdominal wall. 

Diagnosis. — Sarcoma testis with metastases. 

Case 78 

A colored woman of twenty-four entered the hospital August r, 1907. 
Seven months ago she began to complain of a severe steady pain about 
the center of the abdomen, a little more on the left than on the right. 
At this time a large, hard tumor was discovered near the navel. For 
three months following this she had many attacks of pain in the same 
region, and her temperature ranged from ioo° to 105 ° F. The lump in 
the mean time decreased in size. For the last four months she has had 
occasional spells of pain lasting two or three days. She does not feel 
feverish. For the past four months she has had severe epigastric pains, 
coming on every fifteen minutes, lasting two or three minutes, and often 
leading to vomiting, but for the past twenty-four hours she has been free 



EPIGASTRIC PAIN 1 73 

from pain. She has lost twelve pounds in the past seven months, but 
until the last four days has not felt very much weakness. Nose-bleed 
has been frequent all her life, and has been more apt to come at the 
menstrual period. Her bowels have been constipated for years, but with 
medicine have usually moved once a day. Temperature, never above 
99 F. Hemoglobin, 80 per cent.; leukocytes, 8800; urine, normal. 

Physical examination shows nothing abnormal in the chest. The 
abdomen is held very stiffly, especially in the lower portion, where there 
is slight dulness. Much tenderness is complained of throughout. Noth- 
ing else could be made out on account of this tenderness. By vagina a 
band could be felt to the right of the uterus, but the fundus could not be 
palpated on account of abdominal spasm. Immersion in a warm bath 
failed to relax the abdominal muscles, and even under ether the spasm did 
not entirely relax. 

Discussion. — Clinical experience teaches that whenever a negress is 
sick and the symptoms are below the waist, fibroid tumor of the uterus 
usually turns out to be the diagnosis. The abdominal examination was 
so unsatisfactory in this case that nothing definite could be said regard- 
ing the uterus. The lump which was so readily felt some months 
before would play in very well with the idea of a fibroid tumor, but its 
apparent decrease in size, the prolonged fever (three months' duration) , 
and the generalized abdominal spasm do not fit well with this diagnosis. 

Pelvic peritonitis originating in a pus-tube would explain the band 
felt by the vagina and the tenderness of the lower abdomen, but would 
not account for the long fever, the wide extent of the abdominal spasm, 
and the tumor near the umbilicus. Tuberculous peritonitis, however, 
will explain all these facts, and is, moreover, exceedingly common in 
young colored folks. 

Outcome. — On August 7th the abdomen was opened and showed 
tuberculous peritonitis, the viscera irregularly matted together; no fluid. 

Diagnosis. — Tuberculous peritonitis. 

Case 79 

A married woman of thirty-eight, a French Canadian, entered the 
hospital December 10, 1907, for chronic abdominal pain which has lasted 
for several weeks and apparently has incapacitated her for any work. 
This pain has troubled her on and of!" for three years and a half. 
At times it is very severe and interferes much with her sleep. Now 
int every day; formerly she would have respite from it for 
many weeks at a time. It is not affected by eating nor by the time of 
day. Her appetite is fair, and she has never been jaundiced. She 



174 DIFFERENTIAL DIAGNOSIS 

vomits occasionally, the vomitus not being in any way characteristic. 
Her bowels move about once in three days. She has no cough and no 
headache, but thinks she has lost 20 pounds in the past eight months, 
and has been unable to work during that time on account of pain. 

Physical examination showed considerable loss of weight and pallor 
of the mucous membranes. Temperature, pulse, and respiration normal. 
The chest was normal, the abdomen somewhat retracted, rigid, tym- 
panitic throughout, and tender in the epigastrium; no masses felt. The 
blood and urine showed nothing abnormal. 

Discussion. — The symptoms are strikingly like those of the last case 
(tuberculous peritonitis), but in the present case there are weeks of 
freedom from symptoms and no fever has been recorded. All the ordi- 
nary clues suggested by the cases last studied were followed up quite 
fruitlessly. We could obtain no positive evidence of an intestinal stric- 
ture, of lead-poisoning, of peptic ulcer, cholelithiasis, or of any form of 
peritonitis. There seemed no reason to suspect the kidney or any part 
of the urinary tract. 

Under these conditions it is proper to ask ourselves whether the 
symptoms may not be due to pure constipation? It seems extraordinary 
that a loss of 20 pounds in weight should be brought about by this cause. 
Only the therapeutic test, however, can decide the question. If the 
symptoms all disappear when the bowels are properly regulated, and if so 
long as they continue regular there is no recurrence of pain, the diag- 
nosis will be justified. 

Outcome. — Under careful diet, with sodium bicarbonate \ dram 
after meals and mild laxatives, the patient ceased to have pain and left 
the hospital in six days. Her subsequent history has been uneventful 
(1910). . 

Diagnosis. — Constipation. ,J 

Case 80 

A Russian Jew of thirty- two entered the hospital February 11, 1908. 
He has complained for five months of epigastric cramps beginning about 
4 p. M., lasting all night and until noon the next day. In previous 
years he has had similar attacks occasionally. The pain has no relation 
to eating, but on the days in which his stomach has been washed out in 
the out-patient department he has been relieved. He has a good ap- 
petite and eats well, but vomits daily, sometimes spontaneously, some- 
times purposely for relief of distress. The amount of vomitus is large — 
often as much or more than he has eaten since he last vomited. His 
bowels often go five and six days without moving. About a week ago 



EPIGASTRIC PAIN 1 75 

he woke at 2 o'clock in the morning feeling very faint. He soon began 
to be " choked up," and for twenty- four hours had great difficulty in 
breathing. About a year ago he weighed 145 pounds. His present 
weight is 114 pounds. He was formerly a painter, but has had nothing 
to do with lead for thirteen years. 

Physical examination is negative, except that there are tenderness 
and some spasm under the right costal border. The blood and urine 
are normal. His stomach holds 108 ounces of fluid. The contents, ob- 
tained by washing, smell strongly of organic acids, and it is difficult to get 
the wash-water clear. On inflation, the lower border of the stomach 
reaches to a point midway between the navel and the pubic bone. 
Sahli's test was administered, with the following result: 300 c.c. of the test 
fluid were given. After one hour the total residue was 315 c.c, of which 
109 c.c. are test fluid and 206 c.c. secretion; therefore the percentage of 
test fluid passed from the intestine in one hour is 63 per cent, as compared 
with the normal of 75 to 90 per cent.; the hydrochloric acid of the pure 
gastric juice, 3.4 per cent.; average normal, 3.5 per cent. Diagnosis: 
deficient motility with hypersecretion. His chief complaints during his 
stay in the hospital were a burning epigastric pain, flatulence, and con- 
stipation. He received no relief from diet, medication, or gastric lavage. 

Discussion. — We repeated in this case the therapeutic test used so 
successfully in the last, but even when the bowels were in a perfectly 
satisfactory condition, the suffering continued without respite. Con- 
stipation, therefore, was not the trouble; it was the result, not the cause. 

Lead-poisoning was excluded by the study of the blood and the 
gums. 

Tenderness and spasm under the right costal border occurring in a 
patient who suffers from paroxysmal epigastric pain compel us to con- 
sider gall-stones. This possibility cannot be ruled out, and was one of the 
alternatives in the mind of the surgeon who later opened the abdomen. 

Obviously, however, there must be something wrong outside the 
gall-bladder, for the patient's stomach is markedly dilated and does not 
empty itself properly. Gastric stasis, however, may be one of the disas 
Mowing in the train of repeated gall-stone attack and as a result of 
the adhesions thus produced. 

For .u'a^tric cancer that commonest of all causes of pyloric stenosis — 

the history seems to be too long in this case. Vet can we explain the 
»f weight on any other hypothesis? In answering this last question 
vorth while to state emphatically that patients may Lose a fifth or 

a quarter of their weight within a few months as a result either of gall- 
stones or of peptic ulcer. 



176 DIFFERENTIAL DIAGNOSIS 

In the present case all that was certain before operation was the 
existence of an obstruction to the outflow of gastric contents. As a 
cause for this, the scar of a duodenal ulcer and the adhesions resulting 
from repeated gall-stone attacks were the alternatives most seriously con- 
sidered. 

Outcome. — Accordingly, on February 19th the abdomen was opened. 
No disease was found in the stomach, duodenum, or gall-bladder, but 
the pylorus was considerably obstructed by adhesions. Gastro-enter- 
otomy was done. After the operation the patient improved, and by 
March 13th seemed to be in excellent condition except for weakness. On 
May 20th he was discharged, wholly free from gastric symptoms. 

Diagnosis. — Pyloric adhesions. 

Case 81 

A married woman of thirty-two has been complaining for some 
months of acute epigastric pain coming immediately after meals, lasting 
about fifteen minutes, and relieved by the belching of gas. She entered 
the hospital on July 29, 1907. She had suffered from typhoid fever 
at the age of fifteen, from diphtheria at twenty, scarlet fever at twenty- 
two, "peritonitis" five years ago. She has been married fifteen years, 
but has had no children and no miscarriages. Five years ago she weighed 
250 pounds, and she thinks she has gained in weight lately. She is in 
the habit of taking two or three drinks of whisky a week for the " blues." 
Four days ago she ate very heartily at supper-time. At 1 o'clock 
the following morning she was taken with severe epigastric pain, which 
has persisted ever since. 

After palpation of the epigastrium the pain becomes spasmodic 
and seems to go straight through to the back. It is worse with every 
deep breath, and is increased by emotion. 

The bowels were moved last night for the first time during this 
illness, as a result of laxative pills. The pain has prevented sleep, and 
last night she thinks she was delirious. The patient's temperature is 
102 ° F.; pulse, 100; respiration, 30. There is tenderness on percussion 
over the lower part of both lungs behind, but nothing else abnormal is 
made out. The abdomen is somewhat hollow above the umbilicus, 
rather full below; the abdominal wall very thick and flabby. There is 
slight rigidity in the lower part, less in the epigastrium, where the pain 
is worst. Deep pressure elicits expressions of pain in both the lower 
quadrants and in the right hypochondrium. The edge of the liver 
cannot be made out. 



EPIGASTRIC PAIN 1 77 

Next morning the pain was more definitely localized in the epi- 
gastrium, and the temperature and pulse remained elevated, while the 
white corpuscles had risen from 13,400 to 17,000. 

Discussion. — Out of this very checkered past history, with its 
suggestions of dyspepsia, peritonitis, and alcoholism, no clear indica- 
tions for diagnosis emerge. The constipation and the very wide-spread 
character of the pains, both in the back and the front of the body, 
are common features of some types of neurosis, but the presence of 
fever and leukocytosis make neurosis very unlikely. In the foreground 
of the clinical picture are the epigastric pain and tenderness of acute 
onset. Many possibilities may emerge, but at present no clear diagnosis 
is possible. 

The problem here presented is a very familiar one. We have 
good reason to believe that in the course of twenty-four or forty-eight 
hours the diagnosis will be much clearer, but is it not dangerous to 
wait so long? Should not an operation be done at once before more 
dangerous symptoms appear? No definite rules can be given by 
following which we can solve this difficulty in every case. The decision 
rests mainly upon two points of observation: 

1. How sick is the patient? 

2. Is she getting worse from hour to hour? 

An answer to the first question depends on long and mature clinical 
experience. A general impression is gained, of which no very clear 
account can be given. The look of the patient's face and the quality 
of the pulse are perhaps the most important items in the judgment. 

More important is the demonstrable change under observation of 
some of the measurable data, such as temperature, pulse, respiration, 
leukocytosis, the degree and area of spasm, tenderness, and pain. 
While we are watching the course of these variables, it is quite likely 
that the pain and tenderness will have time to "settle." Careful 
observation of most cases of this kind brings out three stages: 

1. The initial pain, its location being of great diagnostic value if 
the history is clear and definite. 

2. The subsequent radiations of this pain, often most confusing. 

3. Its final "settling" in a single spot, most important in diagnosis, 
but often dangerous to wait for. 

The Symptoms do not seem to be violent enough for perforated 

peptic ulcer or for acute; pancreatitis, though neither of these can be 

r':l<-d out. Gall-stones is the next most frequent cause for pain of 

type, provided lead, tabes, constipation, pericarditis, and angina 

led, as Is easily possiMe in the present case. Since 



178 DIFFERENTIAL DIAGNOSIS 

there are fever and leukocytosis, it is reasonable to believe that some 
cholecystitis has also occurred here. 

Outcome. — On the afternoon of the thirtieth of July operation 
showed an enlarged, edematous, partially gangrenous gall-bladder, 
with one faceted stone within. 

The patient made a good recovery. 

Diagnosis. — Cholelithiasis and gangrenous gall-bladder. 

Case 82 

A woman of forty-eight entered the hospital February 14, 1908. 
She has had four children, all of whom are now dead. The first was a 
congenital idiot; the second had water on the brain; the third was 
still-born, and the fourth died at three years of pneumonia. She had 
repeated convulsions during the latter months of her third pregnancy. 
During the others she had no such trouble. She has had no miscarriage. 
Her habits are good, but she has usually passed her water eight or ten 
times each night during the past ten years. 

For the past seventeen years she has had many attacks of epigastric 
pain, with distention and belching. The pain has never been colicky 
or accompanied by jaundice, but has radiated to the back, and has 
sometimes been severe enough to require morphin. The attacks of 
pain have no relation to mental conditions nor to the character or time 
of meals. Her weight is unchanged. 

Two and a half weeks ago she had a sudden attack of pain, worse 
than at any previous time, and vomited several times in the first twenty- 
four hours. She had fever for five days, and has been in bed ever 
since. She has had daily chills, lasting from fifteen to twenty minutes 
each, and recurring about the same hour. Her bowels have been con- 
stipated, and she has taken only liquid food for two weeks. 

Temperature, pulse, and respiration are normal. The patient is 
very obese. The sclera shows a very slight yellowish tinge. The chest 
is negative, and the abdomen shows nothing but general tenderness. 
At a point 2 J inches below the costal margin a rounded edge (presum- 
ably the liver) is felt to descend on inspiration, and there is considera- 
ble tenderness at this point and just above it. The surface of the livei 
seems irregular. The ripht sacro-iliac joint is tender to pressure, and 
she feels better with a pillow under the lumbar spine. Her pain and 
vomiting continued after the patient entered the hospital, and desoite 
laxatives, counterirritants, and starvation. The leukocyte count at 
entrance was 8000, but rose on the third day to 17,000, with 90 per 



EPIGASTRIC PAIN 



179 



cent, of polynuclear cells. The temperature at the same time rose to 
102 F. 

Discussion. — When a woman's pregnancies have resulted as in 
this case, syphilis must always be thought of as a possible cause for any 
subsequent symptoms. The presence of chills and the suggestion of an 
irregular liver point toward that organ as possibly the seat of a syphilitic 
process. On account of such chills I have twice known patients to be 
drenched with quinin for weeks at a time, when syphilis of the liver was 
the true diagnosis. 

In this case, however, the normal temperature makes us wonder 
whether the chills may not be of nervous origin. Trembling and 
shivering are very common nervous symptoms, with or without the sen- 
sation of cold, and under these conditions often get mistaken for a chill, 
which usually carries with it the presence of fever. We are by no means 
certain, however, that the temperature has always been normal previous 
to February 14th; indeed, the patient's statement directly contradicts 
such an idea. At any rate, we cannot be content with the diagnosis of 
psychoneurosis in view of the quite definite physical signs described above. 

Can her troubles all be due to sacro-iliac arthritis? Attention is 
drawn to this point by the tenderness over the sacro-iliac joint and the 
relief following support of the lumbar spine, but the jaundice, enlarged 
liver, and the persistent vomiting cannot be thus explained. Pain and 
tenderness in various parts of the abdomen may be produced through the 
nerve radiations originating in sacro-iliac disease. Both gall-stones and 
appendicitis may thus be simulated. But in this case we have other 
objective signs. 

By far the commonest lesion associated with a picture like that here 
given is cholelithiasis, and although the case is atypical in various respects, 
this seems to be the most reasonable diagnosis. 

Outcome. — Operation showed an enlarged, thickened, and perfor- 
ated gall-bladder, surrounded by a considerable amount of pus, and con- 
taining numerous gall-stones. 

Diagnosis.— Cholelithiasis with perforations. 

Case 83 
A school-boy of thirteen entered the hospital February 14, 1908. 

Tn November and December, [906, he had an acute urethritis, and 
gonococci - ere demonstrated in the discharge. He lias had "rheu- 

m" for about one ve;ir in the pasl three wars, in periods lasting 
from to three months. His family history is not remarkable, 

and he ha eU for the pa ears. 



;[8o DIFFERENTIAL DIAGNOSIS 

Seven days ago he began to have epigastric pain. Five days ago his 
knees became swollen and painful on motion, and he took to his bed, 
where he has since remained. In the past two days his knees have im- 
proved and no other joints have been involved. Yesterday morning he 
began to breathe very rapidly, but has had no cough and no vomiting. 

Physical examination shows slightly labored breathing, with pallor 
of the mucous membranes. Temperature, 100.2 ° F.; pulse, 112; res- 
piration, 28. The heart's dulness extends into the sixth interspace, 
two inches to the left of the nipple-line. The right border extends if 
inches to the right of midsternum. The cardiohepatic angle is ob- 
tuse. All over the precordia, but loudest at the apex, a systolic mur- 
mur and a rough diastolic murmur are heard. The latter is also heard 
over the lower end of the sternum. In the left back there is dulness ex- 
tending up to a point one inch above the lower angle of the scapula, 
thence sloping down through the axilla to meet the cardiac dulness. 
Over most of the dull area bronchial breathing, increased voice-sounds, 
with increased tactile fremitus, and fine moist rales, are heard. At the 
extreme base, where dulness is most marked, the intensity of voice- 
sounds and breath-sounds is very slight. Later a capillary pulse was 
demonstrated, and the diastolic murmur was shown to be loudest along 
the left edge of the sternum, but also fairly loud in the second right 
interspace. 

At no time was there any cough. The leukocytes ranged between 
12,000 and 13,000; the urine was between 30 and 40 ounces in twenty- 
four hours, and free from albumin. 

Discussion. — Obviously, this boy has an arthritis, and gonorrhea 
is its probable cause. The problem of present importance is to deter- 
mine what complications have occurred. Evidently some infectious 
disease is still going on, and the physical signs call our attention especi- 
ally to the heart and the lungs. 

Pneumonia, with or without empyema, would explain the signs in the 
right back, and it is a very familiar fact that pneumonia and pleurisy often 
begin in children with abdominal pain. The absence of cough by do 
means excludes pneumonia. 

But the cardiac signs have also to be explained. The increased area 
of dulness and the double apical murmur are the ordinary evidences of 
endocarditis with disease of the aortic and mitral valve. But the per- 
cussion lines on the right side of the heart (see diagram) are more 
indicative of pericarditis, though no typical friction is described. If 
a pericardial effusion were present, it might account not only for the per- 
cussion outlines and the auscultatory abnormalities, but also for the 




Fig. 29. — Percussion outlines in a patient complaining chiefly of epigastric pain. (See 

also Fig. 30.) 




ble in a case <>f endopericarditis. (Sec also Figi 29.) 



EPIGASTRIC PAIN . n;8i 

signs in the back of the left lung, since this is just the area of lung on 
which a pericardial effusion exerts pressure in bed-ridden patients. 
By such pressure sufficient condensation of the lung is produced to sim- 
ulate the signs of pneumonia. It is impossible to exclude a patch of 
pneumonia complicating the other troubles present, but experience shows 
that we are more apt to be right wtien we explain a clinical picture by 
one diagnosis rather than by two. Pericarditis, therefore, seems the 
most reasonable working hypothesis. 

Outcome. — The temperature gradually subsided in ten days. The 
murmurs disappeared, and the boy seemed entirely well by February 
28th. 

Diagnosis. — Acute pericarditis. 

Case 84 

A sexton of sixty-five was first seen December 16, 1907, complaining 
of paroxysmal abdominal pain relieved only by morphin. About three 
years ago he began to suffer from dyspnea and swelling of the legs. 
This trouble has been present, off and on, ever since, but he notices that 
it is better if he is working hard than if he sits around the house. 

In July, 1907, he had an attack of sudden, cramp-like pain in the upper 
abdomen, accompanied by dyspnea and persistent vomiting of foul 
green fluid. After twenty-four hours the pain was relieved by a sub- 
cutaneous injection of morphin. Since that time he has had similar 
attacks, gradually increasing in frequency and diminishing in severity. 
He now has them every second or third day, but does not vomit with 
them. In the last three months he has noted that during the day and 
night before an attack he passes large amounts of pale urine, and on the 
day following an attack small amounts of dark urine. His abdomen is 
often bloated, but this subsides without treatment. 

Physical examination shows that the pupils are equal and react well. 
The tongue is large and smooth, especially in the posterior portion. 
The apex of the heart extends one inch outside the nipple-line in the 
fifth space. The first sound at the apex is weak, the second sound every- 
where accentuated; no murmurs are heard. Blood-pressure ranges 
between 140 and 160 mm. The artery walls an- stiff and tortuous. 
The abdomen shows general voluntary spasm, and the edge of the Liver 
is felt one inch below the costal margin. Tin? knee-jerks cannot be ob- 
tained even on reenforcemcnt. The urine- averages about .\o ounces in 
twenty-four hours, with a gravity of about 1020. There is no albumin, 
but a few hyaline granular casts are seen in the sediment. The white 
corp re <>ioo. 



1 82 DIFFERENTIAL DIAGNOSIS 

During his month in the hospital the patient had many attacks of 
abdominal pain, always coming on at night, relieved by morphin so 
completely that next morning he felt well and wanted to get up. Nitro- 
glycerin and amyl nitrite were repeatedly tried without any relief. 
Most of the attacks of pain were preceded by slight shortness of breath. 
The patient sometimes vomited during an attack. 

Dr. James J. Putnam examined the patient and said that the loss of 
knee-jerk might be due either to spinal arteriosclerosis or, more prob- 
ably, to the diphtheria of his youth. 

Discussion. — In a patient who has no knee-jerks and complains of 
paroxysmal abdominal pain, the thought of tabes should automatically 
rise in our minds. In this case tabes must remain a possibility unex- 
cluded to the last, though it is very unusual to find the pupils normal and 
the other signs of tabes (lightning pains, sphincteric disturbances, sen- 
sory abnormalities, ataxia, syphilitic history) all absent. 

Angina pectoris (or angina abdominalis) is the natural inference 
when we come to take account of the evidences of failing heart power 
and of arterial degeneration. But angina is almost never accompanied 
by vomiting, and it is rare to find a case absolutely unrelieved by the 
nitrites. 

Though the pain is not in the typical place and has not the typical 
radiations of cholelithiasis, there are a number of points suggesting that 
diagnosis. It would be very unusual, however, to find no fever or chill 
in the history of a patient who has had gall-stone pains for six months. 
Further, the association of the pain with dyspnea and with changes in 
the amount of urine would be very unexpected in cholelithiasis. 

Peptic ulcer might produce such a pain, but the brief paroxysms 
completely relieved by morphin are not at all characteristic of that 
disease. Further, it is very rare to find an active peptic ulcer coincident 
with evidences of failing heart. 

Plumbism, simple constipation, and intestinal obstruction by cancer 
can easily be ruled out. 

It seems to me of importance to notice the background of this case. 
For nearly three years previous to the onset of the symptoms now 
complained of the patient had suffered from dyspnea and edema of the 
legs. Physical examination at the present time seems to indicate that 
this is not due to primary valvular trouble, but rather to vascular degener- 
ation. It is possible that all the symptoms may be due to this same cause 
acting upon different organs. 

It is a well-known fact that in arteriosclerotic subjects there appear 
from time to time a great, variety of paroxysmal attacks which in former 



EPIGASTRIC PAIN 1 83 

years were attributed solely to the obliteration, embolic closure, or rup- 
ture of one or another blood-vessel. In the light of more careful post- 
mortem study we have come to speak of these paroxysmal attacks as 
vascular crises. 1 The idea of vascular spasm takes the place of the older 
idea of gross vascular lesion, in view of the fact that postmortem there 
is often no gross vascular lesion to be found. Under this general head- 
ing of vascular crises belong in all probability many of the transient hemi- 
plegias, monoplegias, aphasias, comas, local or general spasms formerly 
explained as due to permanent anatomic lesions. Cardiac vascular crises 
may be supposed to account for the cases of fatal angina pectoris without 
marked narrowing of the coronary arteries. The gastric and other crises 
occurring in tabes are very possibly to be accounted for in the same way. 

In the present case there are three sets of data supporting the hypothe- 
sis of vascular crisis: (a) The curious urinary changes which strongly 
suggest the "urina spastica" seen in vasomotor affections and hysteric 
states; (b) the swelling of the abdomen during attacks; and (c) the associ- 
ation with dyspnea. 

I have already stated that it is impossible to exclude tabes in this 
case. Were that the correct diagnosis, the mechanism by which the 
attack was produced would be the same as under the hypothesis of vas- 
cular crisis without the other lesions of tabes. 

Outcome. — He died of pneumonia at the end of a month; the 
autopsy showed arteriosclerosis with hypertrophy and dilatation of the 
heart. The celiac axis and the coronary arteries were only slightly 
involved in the arteriosclerotic process. No tabes. 

Diagnosis. — Arteriosclerosis; vascular crises. 

Case 85 

A school-boy of ten entered the hospital January 28, 1908, on ac- 
count of epigastric pain which came on night before last after a supper 
of pork and beans with cheese. It has prevented him from sleeping 
since then. 

I Ee says that it feels as if some one had punched him in the stomach. 
Breathing or gaping gave pain at this point and in the left axilla. He 
has almost constant nausea, and has been feverish since yesterday morn- 
ing. He has a brother who has been treated at the Children's Hospital 
for tuberculosis of the knee. 

\t entrance his temperature was 102. 4 F.; pulse, c;S; respira- 
tion, 30, and accompanied by a grunt. He now complains of pain 
both in the epigastrium and at the top of the sternum. The car- 
1 Fof I 'al's account "f thete crisei sec [>. p. 



1 84 DIFFERENTIAL DIAGNOSIS 

diohepatic angle is obtuse, and over the area shown in the diagram 
(Fig. 31) there is a to-and-fro friction sound, loudest in the second 
right interspace. Physical examination is otherwise normal. The 
white cells number 9600; the urine is negative. The day after entry the 
friction-rub disappeared and the temperature fell to normal on the 
second day. On February 5th he was playing about the ward, and a 
fairly loud systolic murmur was heard at the apex and in the axillae. 
The cardiohepatic angle was now acute. 

Discussion. — Some digestive disturbance is naturally the first ex- 
planation which occurs to us, since the symptoms followed so imme- 
diately upon the taking of a heavy meal; but a simple digestive upset of 
this kind would not account for a temperature of 102. 4 ° F. forty-eight 
hours after. In all probability the digestive upset was a result, not a 
cause, of the present trouble. 

Tuberculosis of the spine is said to be associated with epigastric 
pain, such as is here present, and the presence of tuberculosis in the 
patient's brother makes it proper for us to consider this disease seriously. 
There is nothing, however, in the physical examination to support any 
such idea — no spasm of the erector spinas group and no prominence or 
tenderness of any vertebra; nor are there any indications of tuberculosis 
elsewhere. 

With these two alternatives excluded and with due regard for the results 
of the physical examination the only reasonable diagnosis is pericarditis. 
Indeed, the diagnosis could hardly have been missed except by reason of 
the all too common error — the failure to look for it. 

Outcome. — It was learned subsequently that when the patient was 
three years old he had considerable pain and weakness in his legs, ac- 
companied by fever. Recovery was uneventful. 

Diagnosis. — Pericarditis. 

Case 86 

A brass-finisher of fifty-six entered the hospital on January 30, 1908, 
with a negative history up to eight weeks ago, although he had been 
in the habit of taking about five drinks of whisky a day for a good 
many years. Eight weeks ago he began to have abdominal pain, 
worst in the pit of the stomach. This pain is sharp and piercing, 
almost constant of late, keeping him awake at night. For the past 
week or two it has run up under the left costal margin at times. There 
have been no vomiting and no belching, but he has gradually lost his 
appetite entirely. Food does not affect the pain in any way. His 
weight has fallen 42 pounds in three months. His bowels are regular. 




Fig. 31. — Friction-area and percussion outlines in Case 85. C hief complaint is epigastric 

pain. 



EPIGASTRIC PAIN 



185 



On physical examination temperature, pulse, and respiration are 
normal, likewise the lungs. The heart shows no evidence of enlarge- 
ment, and its sounds are regular and of good quality. At the apex 
there is a faint systolic murmur transmitted to the axilla, heard also 
in the pulmonary area and more faintly in the aortic area. All over 
the precordia and over the left pectoral is heard, during inspiration 
alone, a faint, grating, systolic sound, loudest in the third space and 
anterior axillary line. In the fourth space, near the left edge of the 
sternum, is heard a crackling systolic sound not affected by respiration. 
The aortic second sound is considerably accentuated; the artery walls 
are somewhat thickened. Examination of stools shows nothing re- 
markable, the guaiac test being negative. The stomach was found to 
hold 76 ounces of water. The lower border descended if inches below 
the navel. After a test-meal the gastric contents showed no free hydro- 
chloric acid and no lactic acid; the guaiac test was negative. 

Discussion. — Whisky is so old a friend of this patient that it is not 
likely to begin to disagree with him in his fifty-sixth year. Probably 
it has nothing to do with the symptoms in this case. 

Peptic ulcer might produce such pain, and is perfectly consistent 
with the loss of 42 pounds' weight in two months. But the lack of 
appetite, the entire absence of vomiting and belching, and the short 
duration of the symptoms make this unlikely. 

What are we to make of the curious signs in the chest? Have they 
anything to do with the symptoms complained of? Inspiratory systolic 
sounds, absent during expiration, and best heard along the margins 
of cardiac dulness, constitute the commonest type of so-called cardio- 
respiratory murmur. The phenomenon has no clinical significance 
except that in a considerable proportion of cases it is found to be asso- 
ciated with pleural or pleuropericardial adhesions, which may be due 
to tuberculosis. The same may be said of systolic crackling sounds, 
which occasionally mystify the practitioner. 

It is well to make it a rule always to hunt for evidence of gastric 
cancer when a patient past forty comes to us with a recent and unex- 
plained history of gastric symptoms, mild or severe. Errors in diet, 
worries, and such causes are not apt to take effect for the first time 
after a person has lived fifty-six years. If gastric Symptoms are due 
to any cause other than cancer, careful questioning of the patient will 

Uy prove that they have existed at intervals for years. In the 
-e the evidence of enlargement of the stomach and the absence 

of hydrochloric acid from the gastric contents arc chiefly of confirma- 
tory the history being the important thing. 



1 86 DIFFERENTIAL DIAGNOSIS 

Very characteristic of gastric cancer is the gradual but complete 
loss of appetite in this case. On the other hand, the absence of vomit- 
ing and of any relation between the pain and the taking of food is rather 
unusual. 

Outcome. — His symptoms were somewhat relieved by 10 grains 
of orthoform, given four times a day, and 15 minims of dilute hydro- 
chloric acid, given twenty minutes after each meal. 

The patient died on March 15th. Autopsy showed cancer of the 
stomach. 

Diagnosis. — Gastric cancer. 

Case 87 

A bricklayer of fifty-two entered the hospital April 7, 1908, with a 
diagnosis of gall-stones. His family history and past history were 
negative; his habits good. For three months he has complained of 
pain in the epigastrium, not severe, but worse after eating, and usually 
radiating to the right back. For six weeks he has noticed white stools, 
dark urine, and jaundice. Throughout this time, however, his appetite 
has been good, and he has had no vomiting. 

On physical examination he was found to be deeply jaundiced, 
his lungs hyperresonant in front, with slightly prolonged expiration. 
Over the sacrum was a soft, flattened, subcutaneous prominence the 
size of a dollar. Nothing else was detected on physical examination, 
abdominal palpation being unsatisfactory, owing to constant rigidity. 
On April nth the abdomen became less resistant, and an indefinite 
mass was felt in the region of the gall-bladder. A stomach- tube was 
passed, and the capacity of the organ was found to be 42 ounces of 
water, the lower border extending to a point one inch below the navel. 
No contents were found in the fasting stomach. After a test-meal, 
however, hydrochloric acid was found to be 0.09. Lactic acid test 
and guaiac test were negative. 

Discussion. — Excluding congenital cases, an afebrile, persistent 
jaundice usually presents to us the problem of deciding between three 
causes : 

1. Gall-stones and their effects. 

2. Cancer, either of the pancreas or bile-ducts, occasionally of the 
liver itself. 

3. Cirrhosis. 

Hepatic syphilis is considerably less frequent as the cause of long- 
standing jaundice, and the duration is here assumed to be sufficient 
to exclude the acute infectious and the catarrhal type of jaundice. 



EPIGASTRIC PAIN jgj 

Against gall-stones in the present case is the intensity of the jaundice 
without variation in six weeks, the absence of colic, and the presence of 
a mass in the region of the gall-bladder. Long-standing jaundice due 
to gall-stones is usually associated with a normal sized or contracted 
gall-bladder (Courvoisier's law). It is quite possible, however, that 
the mass in the region of the gall-bladder is not due to distention of that 
viscus. 

Cirrhosis almost never produces an intense degree of jaundice. The 
coloration is slight or moderate. It is rarely associated with pain, and 
usually produces either enlargement of the liver or some evidence of 
portal stasis. 

Cancer then seems the more likely diagnosis; whether it is of the 
pancreas or the bile-ducts we have no means of determining. That it 
is probably not in the liver itself is to be argued from the absence of gastric 
symptoms and of objective manifestations of gastric disease. 

Outcome. — Operation, April 23d, showed moderate enlargement 
of the liver, distention of the gall-bladder, and a mass of hard, apparently 
cancerous, tissue in the region of the pancreas. The patient made a good 
recovery from the operation. 

Diagnosis. — Pancreatic cancer; [chronic pancreatitis]. 

Case 88 

A chef of thirty-two entered the hospital on April 8th with the state- 
ment that his mother had died of a "complication of diseases"; his 
father had had a persistent cough for four years; one brother had died 
of consumption at the age of twenty-four, and a sister died of "rectal 
abscess" at the same age. The patient had been exposed to tubercu- 
losis. 

Ever since he was nineteen years of age he has had attacks called epi- 
lepsy. These have always come during sleep, and do not awaken him. In 
the morning he wakes with a headache and general pains, usually finding 
that he has bitten his tongue. At first these attacks came about once a 
month; now they come only about once in six months. Nevertheless, he 
was well and strong until four years ago, when he vomited about four 
quarts of fluid. Following this he was sent to a hospital for tuberculosis 
and remained there six months, although, so far as he knows, he has never 
had a cough and nothing abnormal has been found in his lungs. Two 
and a half years ago lie weighed 160 pounds; now he weighs 137 pounds. 
habits ar<- good. 

For the past six weeks he has been treated for abdominal pain not 
[y localized. Four days ago he vomited a fev. times, and this vomit- 



1 88 DIFFERENTIAL DIAGNOSIS 

ing has persisted and rather increased since then. In the last two days 
he has vomited up about two quarts of dark-brown material, together 
with some food which he thinks was eaten at least twenty-four hours 
before. His pain is now most severe in the epigastrium and under both 
costal margins. It is sometimes relieved by vomiting, and is never 
worse after eating. Yesterday he noticed palpitation for the first time. 
He has a good appetite, but has had some constipation for three weeks. 

Physical examination was negative except for slight tenderness in the 
left epigastrium and under both costal margins. His vomitus was found 
to contain free hydrochloric acid, and the guaiac test was positive, both 
in the stomach-contents and in the stool. Despite careful diet, he con- 
tinued to vomit and have pain. 

Discussion. — Abdominal symptoms of any kind, when occurring in 
a patient with so strong a tuberculous history, compel us to make a 
most searching examination for evidences of tuberculous peritonitis. 
This is true even when the onset is much more acute than in this case. 1 
But in the absence of fever and of all the local manifestations of tubercu- 
lous peritonitis (free fluid, generalized tenderness, spasm, and tumor- 
like masses) this disease may be excluded. 

Is it possible to connect in any way the history of epileptiform 
attacks with the present symptoms? Such attacks might be due to 
cerebral syphilis, and the same disease attacking the liver and spleen 
might now produce acute abdominal pain. But in the absence of 
any enlargement of the liver or spleen, and without fever, anemia, or 
other lesions pointing to syphilis, we have no good reason for consider- 
ing this disease seriously. 

In the treatment of cases characterized by pain and vomiting I have 
often been misled so as to forget the possibility of chronic intestinal ob- 
struction — misled, I mean, by the prominence of symptoms apparently 
referable to the stomach. Especially when there is constipation, as in 
the present case, this possibility should never be lost sight of; but it must 
remain a mere possibility unless there is other evidence to support it. 
In the present case the positive guaiac test in the stool is all that we 
have in the way of physical signs favoring obstruction. In the absence 
of tumor, visible peristalsis or intestinal noise, chronic obstruction de- 
serves no further consideration. 

If, then, the symptoms are of gastric origin, as seems, on the whole, 
most probable, there are but two diseases deserving serious considera- 
tion — cancer and ulcer. In the absence of alcoholism and of any other 
cause for chronic congestion of the stomach (heart disease, cirrhosis), 

1 As an illustration of the acute onset of symptoms in tuberculous peritonitis see p. 427. 



EPIGASTRIC PAIN 1 89 

cancer and ulcer are the only diseases likely to produce hemorrhage both 
from the stomach and the bowel, associated with persistent vomiting 
and epigastric pain. This likelihood is increased when the patient fails 
to improve after careful dieting. 

Against cancer is the fact that the patient is relatively young, has no 
steady gastric stasis, and especially the persistence of a good appetite. 
The presence of free hydrochloric acid is also somewhat against the diag- 
nosis of cancer. On the whole, peptic ulcer, gastric or duodenal, is the 
best working diagnosis. 

Outcome. — On the fifteenth of May his stomach was opened and a 
puckered scar found on the posterior wall of the stomach. Posterior 
gastro-enterotomy was done. The patient did well. 

Diagnosis. — Gastric ulcer. 

Case 89 

A waitress of twenty-eight entered the hospital on May 5, 1898. 
She said that she had "malaria of the stomach" seven years ago, and 
was sick for three days with fever and chills. At that time she had no 
vomiting and no pain, and has otherwise been well except for occasional 
"chills," until three years ago, when she began to have a gnawing in the 
stomach, coming immediately after eating and followed by gastric 
distention and belching, which continues until about two hours after 
eating. This belching has been worse for the past year. At times 
enormous quantities of gas are expelled with much noise. For relief 
from the gnawing sensation she sometimes makes herself vomit, the 
vomitus usually consisting of about half a pint of white phlegm in which 
she has several times seen specks of blood. Her appetite has been good 
and her bowels regular. 

Physical examination shows a very marked pulsation near the navel; 
over it a thrill is felt and a systolic murmur heard. There is slight ten- 
derness in the center of the epigastrium. The examination revealed 
nothing abnormal. 

The guaiac test in the stool was negative. She was put on a diet of 
Carbohydrate and fats, with a diagnosis of gastric neurosis, and was at 
once relieved of her symptoms. 

Discussion. Any one who had the opportunity to hear the thunder- 
ous noise with which this patient expelled gas from the Stomach would be 

strongly biased, I think, toward a diagnosis of gastric neurosis, for 

explosions are almost always preceded and brought about by the 

habit of "cribbing," or swallowing air, which in turn is usually the result 

The most important question is, can we exclude pep- 



190 DIFFERENTIAL DIAGNOSIS 

tic ulcer? Many of the symptoms suggest this disease, and the patient's 
neurotic constitution by no means excludes it. On the other hand, it 
is unusual for the patient to be relieved of pain and other gastric symptoms 
at a time when the stomach is empty. Though many gastric ulcers exist 
without producing hemorrhages, it would be impossible, I think, to make 
a diagnosis of ulcer in this case unless hemorrhage occurred. The 
specks of blood in the vomitus are, of course, of no special importance, 
and the epigastric tenderness has no diagnostic value. 

The thought of aneurysm is apt to disturb both doctor and patient, 
when, as in the present case, abdominal pain is associated with a marked 
pulsation, palpable thrill, and systolic murmur near the navel. The 
evidences by means of which aneurysm may be excluded in this and 
similar cases have already been fully discussed on p. 142. Malaria was 
considered in the diagnosis of this case, but a careful temperature 
record enabled us to exclude it. The diagnosis remained in doubt, 
gastric ulcer and gastric neurosis being the main alternatives. 

Outcome. — On June 6th she was once more on house diet, up and 
about the ward, and seemingly quite well. With care about diet and an 
improved environment, the patient has continued well up to the present 
time (1910). 

The continued good health, after so short a period of treatment, seems 
to me to argue strongly against ulcer. 

Diagnosis. — Gastric neurosis. 

Case 90 

A Jewess of thirty had been operated on, July 30, 1900, for cholecys- 
titis. The gall-bladder was drained. After this operation she re- 
mained well, and has had three children. She entered the hospital 
March 13, 1907, complaining of epigastric pain of two years' duration, 
coming at irregular intervals, and worse after eating. For the past 
month the pain has increased in severity and has radiated to the back, 
but not to either side; it often awakens her at night. Her bowels are 
constipated, and she has eaten little for the past four weeks, though her 
appetite was previously good. She has lost much strength, and for the 
past four days has remained in bed. 

At entrance and thereafter her pulse ranged most of the time above 
90, and not infrequently reached 120. Her evening temperature was 
usually above 99 F., but below ioo° F. 

Physical examination showed nothing abnormal in the chest. There 
was general abdominal rigidity, especially above the navel, where there 



EPIGASTRIC PAIN igi 

was marked diffuse tenderness. The white cells were 27,000 at entrance, 
and S8 per cent, of these cells were polynuclear. Three days later the 
tenderness was gone, and the leukocytes were found to be normal ; they 
remained so thereafter. The urine was at all times negative. 

Examination of vomitus showed free hydrochloric acid in abundance, 
and a positive guaiac test for blood was obtained. Tube examination 
was negative. In the stool the guaiac test was twice negative. The 
patient complained of marked abdominal pain, but obtained great 
relief from the subcutaneous injection of sterile water. 

The patient was treated by careful feeding, the administration of 
}-grain doses of cocain, and dram-doses of Hoffmann's anodyne for 
gastric distress. On one or two occasions J grain of morphin was 
administered. Nutrient enema ta were tried, but were always expelled 
within a short time. The patient took liquids well after the first few 
days and was, for the most part, free from pain and vomiting. 

Discussion. — The symptoms seem to be very much the same as 
those previously proved to be due to cholecystitis. Since the gall- 
bladder was drained, and probably, for the most part, obliterated, it is 
unlikely that there is any return of inflammation at that point, especially 
as she seems to have had five years of freedom from symptoms. The 
same considerations, however, lead us to wonder whether adhesions 
may not have formed in the vicinity of the gall-bladder, resulting in 
gastric stasis and precipitating the attacks of pain. The absence of 
any gastric stasis, however, as evidenced by the stomach-tube examina- 
tion, makes this supposition less likely. 

The local signs at the time of entrance and the leukocytosis point 
rather toward a local peritonitis, possibly from a gastric ulcer. Were this 
the case, however, we should not expect the disappearance of all these 
signs within three days. One cannot help being influenced by the fact 
that this patient's pain was greatly improved by the " lie cure " (injec- 
tions of sterile water, mistaken by the patient for morphin). 

Chronic appendicitis has not been yet extensively discussed in this 
book, for the reason that I find it hard to arrive at any very definite 
conclusion upon the subject, but certainly this ease is very similar to 
• which surgeons are accustomed to operate on with that diagnosis. 
The childhood attacks often seen in chronic appendicitis are not here 
mentioned. There was at no time any local tenderness OT spasm in the 

right iliac region, nor any radiation of pain to that region. Nevertheless, 
ertainly true thai cases no more typical than this have been relieved 

of all symptoms after the removal of an adherent, kinked appendix. 
In thifl connection I wish to call attention to the following table, which 



192 



DIFFERENTIAL DIAGNOSIS 



embodies the conclusions of Drs. Graham and Guthrie, 1 arrived at after 
the study of a large series of cases from the Mayos clinic: 

DIFFERENTIAL DIAGNOSIS OF THE MILDER TYPES OF CHRONIC 
APPENDICITIS, PEPTIC ULCER, AND GALL-STONES.— (After Graham 
and Guthrie, Jour. Amer. Med. Assoc, March 19, 1910.) 



Disease. 



Chronic appendicitis 
(dyspeptic type) 

Gall-stones 

Peptic ulcer 



Aver- 
age 
age. 



34 



40 



45 



Child- 
hood 



tacks. 



Sequence 

at regular 

interval 

after food. 



+ + 



Severity of 
digestive 
disturb- 



Consider- 
abie. 

Mild. 



Moderate 
in early 
stages. 



Mode of 
relief. 



By pass- 
age of gas 
or feces. 

Sudden — 
often by 
morphin. 



By food, 
soda, 
vomiting, 
or irriga- 
tion. 



Radiations 
of pain. 



To right 
iliac re- 
gion. 

To back, 
right ax- 
illa, and 

right 
shoulder. 



Tempera- 
ment 



Neurotic. 



The conclusions of these observers are borne out by most of my 
observations, and seem to me about as near to wisdom as any yet offered 
upon the subject. 

After very careful study of the case we were unable to arrive at any 
definite diagnosis. We could not definitely incriminate the stomach, 
the gall-bladder, or any other viscus, yet we were by no means certain 
of the absence of severe disease calling for surgical interference. Ac- 
cordingly, on March 24th the abdomen was opened, but careful search 
revealed no disease of any kind. The patient made an uneventful 
recovery. 

Diagnosis. — Gastric neurosis. 

Case 91 

A dressmaker of twenty-three, whose mother died of cancer of the 
stomach, was seen January 28, 1907. She admitted that for a year 
she had taken a great deal of beer, wine, and whisky, and for the past 
two weeks she had taken from a pint to five pints of whisky a day. 
During this last period she had eaten practically nothing, and has 
been in bed most of the time. A few days ago, whenever she closed 
her eyes, she saw big animals and other apparitions. For the past three 
days she has vomited almost constantly, and had some epigastric pain, 
which has become more severe during the past two days, especially 

1 Jour. Amer. Med. Assoc, March 19, 1910. 



EPIGASTRIC PAIN 1 93 

when she breathes deeply. Last night her respiration was very difficult 
and shallow in consequence. There has never been any blood in the 
vomitus. 

Temperature, pulse, and respiration were normal, the left pupil 
considerably larger than the right, but both reacted normally; a heavy 
brownish coat was found on the tongue, and a marked tremor in the 
fingers. The chest showed nothing abnormal. The abdomen was 
rigid and tender throughout; exquisitely so in the epigastrium. Liver 
dulness was not increased, and there was no shifting dulness in the 

flanks. 

■ 

Discussion. — The chief problem in this case is to decide whether the 
alcoholism from which she is suffering will account for all the symptoms. 
We are not accustomed to associate extreme abdominal tenderness and 
rigidity with delirium tremens or with simple alcoholism. On the 
other hand, if perforative peritonitis (stomach, gall-bladder, appendix) 
were present, there should be some rise of temperature, pulse, respira- 
tion, or leukocyte count, none of which occurred. There is nothing in 
the case to justify the suspicion of lead-poisoning, tabes, chronic intestinal 
obstruction, passive congestion of the liver, pericarditis, pneumonia, or 
any of the other causes of epigastric pain which have been discussed on 
previous pages. 

Is it possible that the symptoms may be due merely to the excessive 
vomiting, with the wrenching strain thereby brought upon the abdominal 
muscles? We decided to take our chance of this diagnosis, and planned 
our treatment accordingly. 

Outcome. — The next day the pain was much less, likewise the ten- 
derness and tremor, and there has been no vomiting. By February 3d 
she was entirely free from complaints, and on the sixteenth she left the 
hospital well. 

Her treatment consisted of milk diluted one-third with lime-water, 
4 ounces every two hours when awake; orthoform, 10 grains, every four 
hours; hot stupes to the abdomen every hour when awake; whisky, J 
ounce every four hours; triple bromids, 30 grains, and tincture of cap- 
sicum, 15 minims before meals. After the first two days the whisky was 
omitted. The other medicines were not needed after the thirteenth. 

Diagnosis. — Alcoholism. 

Case 92 

A teamster of forty-eight entered the hospital August 12th. Gas- 
tric ulcer and abdominal aneurysm were the diagnoses suggested by 
the out-patient physician. The family history was not remarkable, 



194 



DIFFERENTIAL DIAGNOSIS 



except that one sister has been in the Worcester Insane Asylum. The 
patient's habits and past history are good. Ten weeks ago he began to 
have steady epigastric pain, usually dull, sometimes sharp. After two 
or three days he had to give up work on account of pain and weakness, 
but he has not been in bed for the whole of any day. Previous to this 
illness he has never had pain of this sort. It is worst about one hour 
after eating, but it is not relieved by food, and does not radiate to any 
other point. During the same period he has also had aches and darting 
pains in his neck, legs, and the right side of his chest. For the past 
two or three weeks he has felt sleepy and nervous in the daytime, while 
at night pain and nervousness have often kept him awake. He has 
headache during most of every morning. The last four or five weeks he 
has been short of breath, but has noticed no swelling of his feet. His 
bowels move only once in four days. His appetite is poor, but he has 
not vomited. 

On examination he seems to be emaciated. The chest shows noth- 
ing abnormal. The abdomen is decidedly concave and somewhat tender 
in the epigastrium, where there is marked pulsation visible and palpable 
from a point two inches below the sternum to a point one inch below the 
navel. Otherwise physical examination is negative, and the blood, urine, 
and temperature-chart indicate nothing abnormal. The patient was 
depressed, seemed very apathetic, and at times refused nourishment. 
The stomach-tube proved that the stomach held 30 ounces of water and 
showed no evidence of enlargement. After a test-meal the extracted con- 
tents showed free HC1, 0.12 per cent., no lactic acid, no blood. 

Discussion. — Although abdominal aneurysm was considered in 
this case, the physical signs are clearly those of dynamic aorta, the differ- 
ential diagnosis of which has been already discussed. (See p. 142.) 

Gastric cancer is always a threatening possibility when a man of 
forty-eight begins to have digestive symptoms for the first time in his 
life. The emaciation present in this case lends support to this hypothesis, 
and the negative results of examination by the stomach-tube do not en- 
able us positively to exclude cancer. We will return to the discussion of 
it below. 

Peptic ulcer does not cause pains so wide-spread as those here de- 
scribed. If this were the diagnosis, we should expect also some relief 
after food, and very possibly some blood in the stomach-contents. Yet 
while ulcer would not account for all the facts here present, we must hold 
judgment in reserve regarding it, as we have already done regarding 
cancer. 

Could the symptoms be explained as the result of simple constipa- 



EPIGASTRIC PAIN 1 95 

tion combined with starvation which his emaciation suggests? Very 
possibly they may, but we still require some reason for the sudden appear- 
ance of constipation in a healthy teamster of forty-eight. 

We cannot afford to leave out of consideration the psychic symptoms 
in this case. A middle-aged laboring-man does not begin to be sleep- 
less and nervous without obvious cause. The ordinary cause for such 
symptoms is alcoholism, which could be definitely excluded here. In 
view of the patient's depression, his persistent headaches, his nervous- 
ness, insomnia, and apathy, a mild type of insanity (depressive maniac 
psychosis) seems probable, especially since no cause for his depression 
can be found in any of the recent events of his life. Assuming this to 
be true, the question remains: Can the abdominal symptoms, the ano- 
rexia, and emaciation be thus explained? To this it is to be answered 
that in sanatoria and asylums for the insane it is a very common ex- 
perience to find the foreground of the clinical picture occupied mainly by 
gastro-intestinal symptoms almost as severe as those seen in organic 
disease. The further course of these cases, however, demonstrates the 
absence of any such disease, and leads us to the conclusion that the 
gastro-intestinal symptoms are simply one item in the symptom-complex 
called insanity. 

Assuming then that this patient is mildly insane, we are justified in 
supposing that his stomach symptoms are dependent upon this psychosis, 
even though, were he normal mentally, we should be strongly inclined to 
believe that he had gastric ulcer or cancer. 

Outcome. — The patient became more and more depressed. Two 
special consultants pronounced the case simple melancholia, and he was 
removed to an asylum. 

Diagnosis. — Melancholia. 

Case 93 

An Italian laborer forty years old had " rheumatism " five years ago 
and one year ago. Many joints were swollen, painful, and tender for 
a few weeks in each attack, but he has regained perfect function in all 
the joints. 

He takes two whiskies before breakfast and four beers during the 
day. Denies venereal disease. 

Few sii weeks he has had gnawing pain in the epigastrium and right 
hypochondrium, gradually getting worse, sometimes disturbing sleep, 

but never influenced by food. Nocturia, t to 3 times. 

Physical Examination.'- 'I he cardiac impulse extends i cm. outside 
the nipple in the fifth space. No enlargement to the right is detected. 



196 DIFFERENTIAL DIAGNOSIS 

Cardiac action regular — 80 per minute; the apex first sound is replaced 
by a long, blowing murmur, which is also audible in the left axilla. At 
the third left costal cartilage is the maximum intensity of a diastolic 
murmur, which is also faintly heard in the second right interspace. The 
pulmonic second sound is accentuated. 

All the superficial arteries pulsate strongly, and there is a "Corrigan" 
and capillary pulse. 

Nails slightly incurved. Lungs negative. 

In the upper right abdominal quadrant is a mass easily felt bimanu- 
ally, descending over an inch on full inspiration, with a rounded edge 
and a semifluctuant consistence. The liver dulness extends 8.5 cm. 
below the ribs (nipple-line) and 12.5 cm. below the ensiform. Whether 
or not the liver is continuous with the mass described above cannot be 
certainly determined. The liver edge is sharp on the left of the median 
line, but cannot be felt distinctly on the right. 

The spleen is palpable 2 cm. below the ribs. Abdomen otherwise 
negative; likewise the rest of the body. Urine, 40 ounces; specific grav- 
ity, 1 02 1. No albumin, pus, blood, or casts. Blood normal. 

Cystoscopy showed evidence of normal functioning in each kidney. 

Discussion. — Clearly enough this patient has incompetence of the 
aortic and mitral valves, presumably of rheumatic origin. The inter- 
esting problem remaining concerns the mass in the right hypochondrium. 
Is it liver, kidney, or retroperitoneal tumor? 

The alcoholic history may have produced a cirrhosis, but cirrhosis 
rarely causes pain, and the cirrhotic liver is hard, not semifluctuant. 
Moreover, we do not expect to feel the liver bimanually, though that is 
by no means impossible. There seems reason to believe that the liver 
is enlarged in this case, but apparently there is something else wrong. 

A mass palpable bimanually in the right flank usually turns out to be 
connected with the kidney, and it was with this in mind that cystoscopy 
was done. The results of this examination go far toward excluding 
renal disease, and were interpreted in this sense. 

Tumors of the retroperitoneal glands produce not infrequently a 
mass like that here described. Diagnosis of such tumors, however, is 
impossible unless there are more definite pressure symptoms (pain in the 
back and legs), or unless there has been malignant disease elsewhere in 
the body, with possible metastasis in the region now under considera- 
tion. 

Syphilis of the liver and cancer of the liver or colon would not account 
for so soft a mass as is here described. Is it possible that simple passive 
congestion due to the cardiac lesion might produce so soft an enlarge- 



EPIGASTRIC PAIN 1 97 

ment of the liver? Against this is the absence of much stasis in the lungs, 
legs, or abdominal cavities, and the fact that the questionable mass can- 
not with certainty be connected with the liver edge palpable to the left of 
the median line. A surgical consultant considered the symptoms due 
to a tumor of the gall-bladder or of the kidney. On the whole, there 
seems to be enough doubt upon this point to justify exploratory lapa- 
rotomy. 

Outcome. — Laparotomy showed the kidneys and gall-bladder to be 
normal. .4 large, dark, congested liver was the only finding. 

This case seems to me to be of unusual interest, since it shows that 
passive congestion of the liver is one of the items which must be seriously 
considered in a diagnosis of diseases involving the right upper quadrant. 
So far as I am aware, this is one of the few cases on record in which 
laparotomy has been done for passive congestion of the liver. 

Diagnosis. — Hepatic congestion. 

Case 94 

A private secretary, sixty years old, entered the hospital March 2, 
1907. Her father died of consumption. She had diphtheria at twelve. 
Twenty-five years ago she had inflammatory rheumatism and ophthalmia, 
was in bed a week, and has had a slight similar attack since. In the past 
thirty years she has had about twelve attacks of colic, characterized by 
sudden painful cramps in the abdomen. The last attack was in July, 
1906. Ten years ago an appendix abscess was opened and drained. She 
has never been jaundiced, but always has had a strong tendency to con- 
stipation. Her best weight w T as 182 pounds six months ago. Six weeks 
ago she had several attacks of indigestion within a week; after this she 
was well until four weeks ago, when she had a sudden severe attack of 
epigastric pain lasting an hour. She has had five or six similar attacks 
since, most of them coming after breakfast and lasting several hours until 
relieved by morphin. 

The pain does not seem to radiate in any direction. For three days 
she has been jaundiced. 

Physical examination showed an obesity and a marked jaundice, 

hut was otherwise negative. By the sixth of March the jaundice had 

d up and the patient was comfortable except for slight sore throat. 

Discussion. — Since tuberculous peritonitis may manifest itself for 
the first time with symptoms as acute as those here present, it deserves 
a moment'- consideration, especially in view of the tuberculous family 

there are no physical signs corresponding to this disease, 

in the al fever it need QOl be further discussed. 



1 98 



DIFFERENTIAL DIAGNOSIS 



Attacks of abdominal pain in a patient who has no knee-jerks should 
always remind us of tabes, yet there are no other confirmatory facts, 
and it is quite possible that the diphtheria which the patient passed 
through at the age of twelve may have produced a neuritis which 
accounts for the loss of knee-jerks. 

In elderly persons with a strong tendency to constipation we need 
no further explanation for many uncomfortable abdominal symptoms; 
but constipation practically never produces pain so sharp as to require 
morphin unless, indeed, it be due to organic obstruction. Her age and 
the character of the pain are quite consistent with this diagnosis, and 
experience has shown that intestinal obstruction is always a serious 
danger for those who have been operated upon for appendicitis, especi- 
ally if the formation of adhesions has been favored by drainage of the 
wound. But if the intestine were obstructed, we should expect disten- 
tion and vomiting, while the attacks of pain would probably not occur 
so frequently and at such short intervals. 

Peptic ulcer is, as in so many cases, a possibility impossible to exclude, 
but the presence of jaundice, the sudden relief by morphin, and the 
absence of any definite relation between the pain and the taking of food 
turn our attention rather to gall-stones. Since the appearance of the 
jaundice this diagnosis has been tolerably obvious. It is favored by 
the age and sex, the obesity, and the character of the pain. 

Outcome. — The abdomen was opened on the ninth of March, and 
showed a small gall-bladder completely filled with stones. 

Diagnosis. — Gall-stones. 

Case 95 

Mrs. H., a widow of seventy, was seen in consultation November 
8, 1 901. Her mother died of old age at eighty-one; her father of dia- 
betes at sixty. Three sisters died of pulmonary tuberculosis; one from 
an accident; one of unknown cause; one is still living. 

Mrs. H. has had ten children: By first husband, eight; two of these 
died of pulmonary tuberculosis, one of "dropsy"; one daughter died 
from "effects of a surgical operation"; three died in infancy, cause 
unknown; one living. The two children by her second husband are 
living and well. 

She had the usual children's diseases, but otherwise was always 
well until 1890, when she had strangulated hernia and was operated 
upon. During the following year she did not feel well, had fever, 
chills, vomiting, and pain, and in 1891 was operated for right empyema. 
This discharged for six months, but finally healed. Since that time 



EPIGASTRIC PAIN 



199 



she has complained of dyspepsia, sour, bitter eructations, dull pain 
in epigastrium, headache, malaise, and gradual loss of flesh — about 
20 pounds in all. 

In May, 1901, she had an attack of severe pain hi the epigastrium, 
midway between umbilicus and ensiform; the pain was relieved by hot 
drinks. A month later had a similar attack; a physician was called, 
who said it was acute neuralgia of the stomach. He gave her something 
to make her vomit, and she vomited for twenty-four hours almost con- 
tinuously, the vomitus consisting mostly of "green, bitter stuff." She 
had a similar attack September 1, 1901, relieved by hot drinks. There 
was some vomiting in this attack. Next attack, September 8th; then, 
September 14th; the last two relieved by morphin, J grain. The final 
attack about October 19th. This last attack was the most severe. Be- 
tween attacks patient was fed on liquids and semisolids, and complained 
of no pain or indigestion. The pain seemed to start at a spot in the 
right back on the level of the sixth or seventh rib, radiating straight 
forward to "pit of stomach," thence down the left side of the belly. 
There was nothing to be seen at this dorsal spot, but it was painful to 
touch. After receiving a subcutaneous injection of morphin, she began 
to vomit and continued to vomit about every half-hour for thirty-six 
hours. She became very weak, but had a normal temperature and a 
pulse of 60. She passed but little urine during this thirty-six hours, 
but at the end of it she voided nearly two quarts. Examination of this 
urine showed specific gravity 1022, color high, about 0.1 per cent, of albu- 
min. Sediment contained few hyaline and fine granular casts, with fat- 
drops adherent. A specimen of urine sixteen hours later was smoky, con- 
tained 0.1 albumin, and in addition to sediment in previous urine was 
full of blood and calcium oxalate crystals. The patient now complained 
of pain in both flanks and soreness all over abdomen, especially on right 
side. The temperature now is ioc° F. and pulse 88. There is headache. 
Blood-pressure, 145. No jaundice now or in any of these attacks, but 
the patient says she always looked a little yellow. 

She is a well-preserved lady, rather fat. Liver normal in size. A 
point of extreme tenderness is situated halfway between ensiform and 

umbilicus. Heart and Lungs negative. Colon distended with gas. The 

sclera near the iris is clear blue. On drawing back the eyelid a slight 
of yellow is visible at the periphery. 
Discussion. — Intestinal obstruction is naturally our first thought 
When a patient complains of acute abdominal symptoms with persistent 
Vomiting, and has previously had an operation for Strangulated hernia. 
But in t! there is no abdominal distention, no constipation or 



200 DIFFERENTIAL DIAGNOSIS 

diarrhea, no visible peristalsis, and an unusual degree of comfort between 
attacks. 

When a patient is relieved as markedly as in this case by the 
taking of hot drinks, gastric flatulence with pyloric spasm seems a 
natural explanation. But this symptom in practically all cases is 
dependent upon some deeper cause, such as peptic ulcer or gall-stones. 
The long history of dyspepsia leading up to sharp attacks of pain is 
consistent with either of the above diagnoses, which will be further 
discussed below. One of the confusing elements here is the condition 
of the urine. Can the symptoms be due to uremia, which is traditionally 
supposed to lead to attacks of abdominal pain in certain cases? The 
urine does not suggest acute nephritis, and if any type of chronic nephri- 
tis were present, there should be hypertrophy of the heart and a higher 
blood-pressure. In all probability, therefore, the urinary findings 
are to be explained as the result of some toxic irritation of the kidney, 
and are not of any serious significance. In one of the later examinations 
the presence of macroscopic blood in the urine is noteworthy as sug- 
gesting a possible stone or tumor of the kidney, but one remarks that 
this specimen of urine was passed not long after the bladder had been 
emptied of two quarts of urine following an acute retention. This 
chain of events is notoriously prone to produce hematuria. On the 
whole, then, in the absence of any palpable mass in the kidney region, 
there seems no good reason to suspect that organ. 

We are left with the two diseases so often suspected and discussed 
heretofore — gall-stones and , peptic ulcer. The tender spot in the 
back corresponds rather to the pain of gall-stones than to that of ulcer, 
and it is especially significant that in one of the attacks the pain started 
at this point and radiated thence forward. The immediate relief of 
pain by morphin and the absence of indigestion between attacks incline 
us to the diagnosis of gall-stones, especially since the less accessible 
portions of the sclera have begun to show a yellowish tinge. 1 

The prolonged vomiting after the administration of morphin is 
presumably to be ascribed to one of the not uncommon idiosyncrasies 
in relation to this drug. 

Outcome. — Next day slight jaundice was evident in the sclera. 
This gradually deepened until her skin was almost a coffee color. 

1 It is perhaps worth noting here that when we are expecting or suspecting a slight 
degree of jaundice, we should examine especially the peripheral portions of the sclera, 
which show a yellowish tinge long before there is any coloration around the iris. It is 
only in the more pronounced grades of jaundice that the yellow color actually meets the 
iris. Attention to this point sometimes renders the more delicate tests of the serum un- 
necessary. 



EPIGASTRIC PAIN 2 OI 

The stools were carefully sifted, but no stone found. Liver tender. 
In two days the gall-bladder could be felt. Urine heavy with bile; 
stool clay colored. Temperature, ioo° to ioi° F.; pulse, 80 to 100. 
Pain in both flanks. The spot on her back has developed into a mark 
that looks as if some local application had been made. It is shaped 
like this : > has sharply defined edges, is not tender, not swollen, and 
not hot. 

Operation showed stones in the common duct 

Diagnosis. — Gall-stones. 



202 



DIFFERENTIAL DIAGNOSIS 



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Causes of Pain in the Right Hypochondrium 



1. PASSIVE CONGESTION OF THE UVER 



2. GALL-STONES] 
AND ACUTE 
CHOLECYS- 
TITIS 



3. HIGH APPENDIX 

(INFLAMED) 

4. CANCER OF T 

LIVER 



648 



70 



25 



5. URETERAL STONE ■ 15 

6. RENAL STONE I 10 

7. PEPTIC STONE I 9 

8. SUBDIAPHRAGM-1 

ATIC ABSCESS / 

Rarer causes are: Hydro- and pyonephrosis, renal and perirenal 
infections, sacro-iliac lesions, and retroperitoneal neoplasms. 



204 



CHAPTER VI 



RIGHT HYPOCHONDRIAC PAIN 



C3 3FlGinEHBHEEEraGiK3E 



Case 96 

A boy of twelve entered the hospital April 6, 1908, complaining 
of tenderness and pain in the right hypochondrium. He had a tempera- 
ture of 100 ° F. Gall-bladder inflammation was the diagnosis suggested 
by his physician. His previous and family history suggested nothing, 
but he had been suffering almost constantly for two months with the 
pain above described. This pain has been gradually growing worse, 
and is now aggravated by deep inspiration. Occasionally he has a 
sharp pain in the right shoulder; otherwise than this he has had no 
symptoms, and has been able to go to school until five days before his 
entrance to the hospital. He has 
been decidedly constipated. 

Physical examination showed that 
the heart's impulse was best seen 
and felt in the fourth interspace, 
just outside the nipple-line. The 
sounds were regular and of good 
quality. A soft systolic murmur was 
heard at the apex, not transmitted 
widely; the pulmonic second sound 
was slightly accentuated; the pulse 
not remarkable. The lungs were 
normal, likewise the abdomen, with 
the exception of tenderness and con- 
siderable voluntary spasm in the right 
hypochondrium and right iliac fossa. 
The temperature record is shown 
in the accompanying chart. The 
leukocytes numbered 9200 April 7th. 

ril 8th, two days after entrance, the temperature rose to 102.40 
; A the pain increased. A surgical consultant saw the boy, and 
said that the ease was one for exploration of the bile duets, but it was 

20;, 




Fig. 32. — Chart of case 96. 



206 DIFFERENTIAL DIAGNOSIS 

decided to wait until the boy's parents could be communicated with. 
In the meantime, dulness and diminished breathing were found in 
the lower right back, and on April ioth the abdominal rigidity had 
almost disappeared. On this day a hypodermic needle was intro- 
duced in the back over the dull area, but no fluid obtained. An x-ray 
taken April 13th showed no lesion of the lung or pleura and no enlarge- 
ment of the cardiac area to the right. So far the diagnosis was wholly 
in doubt. 

April 15th, nine days after entrance, a double pericardial friction 
sound was heard for the first time, and the right border of cardiac 
dulness on the level of the fifth rib was found to be two inches from the 
midsternal line. 

Discussion. — Gall-stones are so rare in boys of twelve that one 
should be very slow to make the diagnosis, no matter how much the 
symptoms resemble that disease. Pain and spasm constitute the 
whole of our positive evidence pointing toward gall-stones, though the 
fever shown on the accompanying chart would be quite consistent with 
gall-bladder inflammation. Without more characteristic colic, with- 
out jaundice or palpable gall-bladder, we should not make the diagnosis 
of gall-stones until every other possibility has been disproved. 

Abdominal pain in children always points toward disease of the 
chest (pneumonia or pleurisy) as well as of the abdomen. In the well- 
meant desire to solve the problem through some diagnosis of this kind 
an area of dulness and diminished breathing was worked out in the 
lower right back, a most dubious region, owing to the varying height 
of the liver dulness. Such signs as were found were not substantiated 
in any way by the results of exploratory puncture and x-ray examina- 
tion. In view of this they maybe set down as hallucinations of hearing, 
due to what the psychologists call "expectant attention." 

From the lips of the majority of physicians we should surely hear 
of "rheumatism" or "neuralgia" as explanations of an obscure pain 
like this, but in the present case these antiquated blanket-diagnoses 
may be excluded without qualification. Boys of twelve do not have 
neuralgia or rheumatism at the sites where pain is complained of here. 
We must demand that the pain shall be localized at or near a joint 
before the word "rheumatism" can find any place, while all pain called 
"neuralgic" should follow the known anatomic course of some nerve. 

Inflammation of an undescended (subhepatic) appendix is suggested 
by the position of the pain and spasm. The onset has not been as 
sudden nor the leukocyte count as high as in most cases of appendicitis 
associated with so much fever and pain. Nevertheless, until the spasm 



RIGHT HYPOCHONDRIAC PAIN 207 

disappeared and the pericardial friction made itself apparent, a "high 
appendix" could not be ruled out. 

We may ask ourselves whether the position of the cardiac impulse 
(fourth interspace, just outside the nipple) indicates any pathologic 
condition or has any bearing upon the diagnosis. The answer should 
be in both cases, no. At this boy's age the heart's apex is not infre- 
quently thus situated. 

Until the appearance of the pericardial friction-rub I do not believe 
that a diagnosis could have been made in this case, nor do I believe 
that the pericarditis, which ran its course in so typical a way after that 
date, was itself the cause of all the previous symptoms. There seems 
to me good reason to believe that many infections, especially in young 
people, are in their early stages as wide-spread and unlocalized as their 
symptoms. It is probably by a further step in the progress of the infec- 
tious process that inflammation appears in a well-marked circum- 
scribed area with an exudate and the resulting pathologic changes. 
It was with the idea of producing such a localization of a previously 
general process that French physicians have employed subcutaneous 
injections of turpentine to bring about what they call a "fixation ab- 
scess." 

Possibly blood cultures would have helped us in this case. They 
must be, for the present, our only means of recognizing many infections 
in their early, unlocalized stage. 

Outcome. — On the nineteenth the area of cardiac dulness had con- 
siderably increased in size, and now extended well out into the left axilla. 
The leukocyte count had meantime risen from 9200 at entrance to 
19,900 on the eighteenth. The friction sound had meantime disap- 
peared, while dulness and diminished breath-sounds were detected in 
the left lower back. 

On the twentieth dulness in the left axilla was found to extend 
nearly to the posterior axillary line. The leukocytes numbered 22,000, 
with 80 per cent, of polynuclear cells. The diagnosis of pericardial 
effusion was then made, and a trocar was inserted in the fifth space, one 
inch outside the left nipple, and just beyond the palpable cardiac impulse . 
of turbid, blood tinged fluid were obtained, with a specific 

gravity of 1022; 2.1 per cent, albumin. The sediment of this fluid 

showed 87.5 per cent, of polynuclear cells. Xo tubercle bacilli were 

I. Immediately after the tapping a double friction sound could 

again be heard all over the precordia, and great pain was complained 
of in this region. Pain and audible friction continued, with some inter- 
vals of relief, during the nexl three days. 



208 DIFFERENTIAL DIAGNOSIS 

April 23d the case was again seen by a surgical consultant, and on 
the twenty-fourth the pericardium was opened and drained by resecting 
a costal cartilage. The boy afterward developed a left pleural effusion, 
which finally became purulent, but after rather a tedious illness he 
completely recovered. 

Notes of Treatment. — The bowels were moved by calomel, \ grain 
every fifteen minutes until ten doses were given; afterward by cascara 
and by an enema. For the pain, hot fomentations and turpentine 
stupes were given. A mustard poultice to the abdomen also gave some 
relief, and later an ice-bag was placed over the heart and about J grain 
of morphin was given daily by subcutaneous injection. 

Diagnosis. — Pericardial effusion. 

Case 97 

A highly neurotic Jewish boy of eighteen was seen June 19, 1907. 
His illness began in November, 1906, when for two weeks he was troubled 
by pain in the right loin and right back, together with "dizzy headaches" 
and weakness in his legs. He believes that he strained himself in lifting 
a heavy packing-case in October, 1906. In the latter part of December 
he had a similar but milder attack. He states that since January 20th 
he has suffered from constant pain in the right loin, frequently catching 
him with a severe stitch on inspiration. Occasionally the pain has 
shot down from his side toward the groin or up toward the epigastrium. 
His urine is usually clear, but sometimes stained red, and full of floating 
particles. He has gained in weight, but lost in strength since February. 

In January he was carefully examined, but no disease found. On 
June 12th his urine showed a slight trace of albumin, with many 
leukocytes and blood-cells in the sediment. On June 19th a physical 
examination was negative except that the right rectus abdominalis was 
spastic, and there was tenderness over the right side, most marked at 
the edge of the ribs, in the right nipple-line, and in the right iliac 
fossa. 

At the time of this examination the lower edge of the right kidney 
was palpable on deep inspiration, and there was a slight tenderness 
along the lower dorsal and lumbar spine. The movements of the spine 
were free. He had no fever and no increase in the leukocytes. The 
urine varied greatly in gravity, being twice below 1008 and three times 
above 1020 within twenty-four hours. It always contained a very slight 
trace of albumin, and in the sediment a very small number of blood- 
cells and leukocytes. One specimen showed a blood-clot the size of a 
bean. 



RIGHT HYPOCHONDRIAC PAIN 200, 

Cystoscopy was done on the twenty-sixth, and showed on the floor 
of the bladder u a brownish, cylindric, putty-like plug." The orifice 
of the right ureter was greatly dilated, and a little pus was seen to issue 
from it. A strong, clear stream of urine issued from the left ureter. 

Discussion. — In the actual presence of this patient it was far more 
difficult than in reading the printed case to avoid being unduly impressed 
by his neurotic temperament. Any one so manifestly and annoyingly 
self-centered, especially if he be of the Jewish race, runs a considerable 
risk of being falsely accused or falsely suspected of being "merely a 
neurotic." Our better judgment, however, should make it clear that 
there is something else in the background. 

The patient himself was inclined to attribute all his symptoms to 
the strain suffered in the previous October, but on careful questioning 
it was clear that the symptoms did not make their appearance until 
some weeks after the date of the supposed strain. 

We may note that in the physical examination there are no data 
regarding the condition of the sacro-iliac joints. Many of the symptoms 
here described could be accounted for by some of the acute lesions of 
those joints. In fact, however, the joints were normal, although this is 
not stated in the text. 

The chief moral of this case is the impossibility of a satisfactory 
diagnosis through the ordinary methods of physical examination in 
many cases involving the right upper abdominal quadrant. Without 
cystoscopy a "high appendix" (see case 96) could not have been excluded, 
and the diagnosis must have remained long in doubt; indeed, the case 
is introduced largely to illustrate the importance of cystoscopy in cases 
involving neither bladder symptoms nor ordinary "renal colic." 

It remains merely to discuss what lesion we should expect to find 
in the kidney on the basis of the facts here given. Malignant disease 
of the kidney is rare at eighteen, and cannot be recognized in the absence 
of tumor and hematuria. Tuberculosis of the ^kidney should produce 
fever, pyuria, and vesical discomfort. In the majority of cases also a 
tumor would be palpable after eight months of suffering. Renal stone 

ms the most reasonable diagnosis. 

Outcome. — An v ray plate taken on the twenty eighth showed a 
shadow apparently in the pelvis of the right kidney. On the same day 
operation confirmed the findings of tlre.v ray, though the stone crumbled 
ip into fine sand when touched. The patient made a good recovery, 

Diagnosis.— Renal stone. 
11 



2IO DIFFERENTIAL DIAGNOSIS 

Case 98 

A factory-hand of twenty-six, whose family history was unimportant, 
had typhoid fever when he was eight years of age, and has suffered from 
constipation for the past ten years. With the exception of 20 cigarettes 
a day, his habits are good. 

For the past four months he has been more constipated than usual, 
his bowels moving only once in four or five days. For the past two weeks 
he has been troubled by headache, which, however, has disappeared 
to-day. During this time his appetite has been poor. 

Eight days ago he began to have a steady, moderately severe pain 
at the right costal margin. Five days ago he noticed that his eyes 
were yellow, and that his urine was of a deep-red color. 

On physical examination his sclera was found to be moderately 
yellow, and his skin considerably discolored. Both tonsils were slightly 
enlarged, and there were a few white spots upon the right tonsil. The 
heart's impulse was not seen or felt. The sounds were best heard in 
the fourth interspace, three inches from the median line. There were 
no murmurs nor other modifications of the sounds. There was rigidity 
in the right upper quadrant, with tenderness and dulness extending 
an inch and a half below the ribs. A sharp edge could be felt to descend 
on full inspiration at this point. The upper border of liver dulness was 
at the sixth rib. The abdomen was otherwise negative, as were the 
other organs. The urine contained bile and a very slight trace of 
albumin, but was otherwise normal. There was no anemia and no 
leukocytosis. 

The patient was first seen on the twenty-second of February. Under 
sodium phosphate, 20 grains after meals, and a hot-water bag to the 
hypochondrium, he became comfortable, and by March 4th his yellow 
color had considerably faded. His constipation was later treated by 
cascara and by enemata. 

Discussion. — Any case involving jaundice and a past history of 
typhoid fever suggests a typhoid cholecystitis with the resulting gall- 
stones, and this possibility cannot be excluded here. Without colic, 
fever, chills, or vomiting, and without a palpable gall-bladder, we 
cannot get beyond suspicions in this direction. 

Cases of relatively short jaundice, with or without slight enlargement 
of the liver, such as is here present, are traditionally labeled as " catarrhal 
jaundice" if nothing more definite appears in sight; but it is always 
quite possible that we may be dealing in these cases either with a transient 
obstruction due to stone or to an infectious cholangitis traveling down 



RIGHT HYPOCHONDRIAC PAIN 211 

the ducts rather than up. There is little if any proof that so-called 
catarrhal jaundice spreads upward from an inflamed duodenum. For 
the present, however, and until our knowledge of the subject is con- 
siderably increased, we must be content with the old term. 

Outcome. — On the fifteenth of March his color was practically 
normal and the bile was gone from his urine. He felt perfectly well 
and was discharged. There has been no recurrence in three years. 

Diagnosis. — Catarrhal jaundice. 

Case 99 

A widower of seventy-seven entered the hospital February 25, 1908. 
He has always followed the trade of carpenter and has been strong 
and well except for two attacks of malaria, one during the Civil War 
(when he served for three years), and the other eight years ago. 

Seventeen years ago he was kept out of work for fourteen months 
on account of symptoms supposed by one doctor to be due to cancer 
of the stomach, by other doctors to be caused by liver trouble. At that 
time he suffered pain under the right costal margin; this pain shot 
through into his back and was associated with vomiting and frequent 
black stools. He never vomited blood, was never jaundiced, and had 
no chills, fever, or colic. The pain was always worse at night, but had 
no relation to the character of food nor to the time of taking it. 

He completely recovered from this attack, and has been at work 
ever since except for a period of two months, seven years ago, when 
he was in the Massachusetts General Hospital for an attack diagnosed 
as duodenal ulcer. At that time he frequently passed blood in his 
stools and his weight fell to 200 pounds, where it has since remained. 

One year later he had an attack of vomiting with tarry stools, similar 
to those passed the year before, but was well again in a few days. Three 
years ago he had an attack of vomiting lasting nine hours; there was 
no blood in his stools at that time, but he had to remain in the house for 
two weeks. Between the attacks, /. <\, for most of the last fifteen years, 
he has called himself well. Twenty months ago he had a severe attack 
of pain under the right costal margin, accompanied this time by the 
appearance of a red spot on the skin just below the ribs. He was told 
by hi • that he probably had an abscess of the liver. After a 

' of this pain his urine suddenly became pink and remained 
or ten days; the pain and the red spot then gradually subsided, 
and the urine became normal in appearance. 

-1 . he had an attack of indigestion, with pain under the right 



212 DIFFERENTIAL DIAGNOSIS 

costal margin and fainted, so that he fell out of his chair while the 
doctor was talking to him. His habits have always been excellent. 

For the past six months he has had a continuous, dull pain under the 
right rib-margin. This pain gets worse on moving about, is not affected 
by food, and occasionally becomes severe, radiating to other points of 
the abdomen and to the back. He had such an attack three nights 
ago, but was relieved by drinking three glasses of cold water. 

, Six weeks ago he noticed under the right costal margin a swelling, 
which has steadily increased in size and become exceedingly tender 
to the touch. He has had no fever, no jaundice, no vomiting, and no 
change in the amount or color of his urine. He has noticed nothing 
remarkable about his stools. 

Physical examination reveals no emaciation and nothing abnormal 
in the chest. The right costal margin is markedly prominent, and in 
the center of this prominence is a rounded protrusion which is very 
tender. (See Fig. 33.) The tender mass is firm and somewhat movable, 
sometimes reaching the median line in the epigastrium. The edge of the 
liver is felt just below the mass, and is apparently somewhat irregular. 

Physical examination is otherwise negative, likewise the blood and 
urine. His stools contain no occult blood. After further observation 
it was found that the tumor would move with a change in the patient's 
position until it reached the left costal margin; with this motion the 
upper border of liver dulness also moved downward. Examined by 
means of a stomach-tube, the stomach was found to reach one inch 
below the navel when inflated. The upper border was at the tip of 
the ensiform cartilage. The stomach-contents after a test-meal showed 
hydrochloric acid, 0.11 per cent., and total acidity, 0.17; no occult 
blood. 

Discussion. — The early history of this case points straight to the 
diagnosis of duodenal ulcer. Between these initial symptoms, how- 
ever, and the sufferings of the last six months, there are two curious 
episodes which may be first briefly discussed. 

How are we to explain the appearance of the red spot in the right 
hypochondrium and the close sequence of pink-colored urine? Since 
these symptoms began together and ceased together, it is reasonable 
to look for a common cause. We may conjecture that the spot on 
the hypochondrium was due to a "purpuric" extravasation of blood, 
and that the urinary oloration was due to a similar ecchymosis in the 
kidney. Such occurrences would be easily explicable were jaundice 
present, for we are well accustomed to see all sorts of oozing and hemor- 
rhages in jaundiced patients. It has been pointed out, however, by Dr. 




Fi K- 33-— Diagram of signs recorded in a patient who complains of pain and swelling 

under the right ribs. 






RIGHT HYPOCHONDRIAC PAIN 213 

Maurice H. Richardson and others, that the hemorrhagic tendency in 
diseases of the liver is not confined to those which produce jaundice. 
If, therefore, we assume, as seems warranted by the outcome of the 
case, that this patient may have had liver disease at the time of the 
phenomena we are now attempting to explain, the idea of multiple 
hemorrhage would be plausible. 

What shall we say of the fainting attack which occurred a year ago? 
Since this patient has had repeated and profuse intestinal hemorrhages, 
presumably from duodenal ulcer, it seems not unlikely that the faintness 
was due to the repetition of such a hemorrhage. 

Coming now to the events of the last six months, we find them 
characterized by continuous pain in the region of the liver, apparently 
unconnected with the taking of food, but complicated later by enlarge- 
ment and irregularity of the liver. 

In patients who have never lived under conditions favorable to 
hydatid infection (association with sheep and sheep-dogs, especially 
in Greece, Australia, and Iceland), we need consider only two diseases 
to explain a nodular enlargement of the liver, viz., cancer and syphilis. 
The nodules due to cirrhosis are rarely if ever palpable through the 
abdominal walls. The hepatic enlargements due to passive congestion, 
fatty infiltration, leukemia, pseudoleukemia, amyloid disease, obstruc- 
tive jaundice, and abscess do not produce a nodular surface. Our 
problem, then, is reduced to narrow limits — cancer or syphilis. I 
have never known syphilis to produce so much pain as was suffered 
in this case. The absence of fever is also against this diagnosis. The 
same is true in a lesser degree of the absence of syphilitic history and 
syphilitic lesions in other parts of the body. 

Cancer of the liver — which seems the most probable explanation 
of this man's present sufferings — is rarely primary. We may suppose 
it to be secondary to a growth implanted in the site of the peptic ulcer 
which we have good reason to believe existed some years ago. Yet 
we have no definite evidence of any such growth in the stomach or 
duodenum, and the starting-point of the disease must be left in uncer- 
tainty. 

Outcome. — On the seventh of March the: abdomen was opened 
and showed a firm, nodular mass of malignant disease in the liver about 
ize of a cocoanut. The abdomen was closed and the patient left 
the hospital on the nineteenth of March. He died three months later. 

Diagnosis. — Hepatic cancer. 



214 DIFFERENTIAL DIAGNOSIS 

Case 100 

The patient is a stable-man of thirty-six who was first seen March 
7, 1908. He had a good deal of trouble with his stomach three years 
ago, but since then has been well until four weeks ago, when he began 
to vomit and to have severe pain in the right upper quadrant. His 
vomitus sometimes contains large quantities of food. The pain is very 
severe, and for the last two weeks has forced him to walk the floor every 
night and to take morphin tablets. 

At present his pain is at its worst about two hours after meals; it is 
also very troublesome at night: sometimes it shoots across to the left 
costal margin and up to the right nipple. For three weeks he has eaten 
only bread, milk, and tea. 

On physical examination his right pupil was found to be slightly larger 
than his left. Both react normally. The skin was everywhere notably 
smooth and satin-like to the touch. His radial arteries were considerably 
thickened, and his aortic second sound was greater than his pulmonic; 
otherwise nothing wrong was found in the chest. There was moderate 
tenderness in the right upper quadrant. Physical examination, includ- 
ing the blood and urine, was otherwise normal. A stomach-tube passed 
before breakfast showed no fasting contents. The capacity of the 
stomach was 24 ounces, and the percussion outlines after distention 
with air indicated no dilatation of the organ. Microscopic and chemical 
tests of the gastric contents after a test-meal revealed nothing abnormal. 

It was later ascertained that this attack followed a debauch in which 
he took whisky, beer, and ale to excess for a week, "which," he says, 
"scalded his insides." Before that he had taken no liquor for years. 

Discussion. — By force of ancient tradition we are accustomed 
to think of syphilis as a cause for all pains which are worse at night. 
We have seen, however, from the cases already studied in this book, 
that pain due to hyperchlorhydria, to peptic ulcer, gall-stones, and 
lead-poisoning, is also aggravated at night in many cases. In the pres- 
ent case the suspicion of syphilis is somewhat increased by the finding 
of thickened radial arteries, accentuated aortic second sound, and 
unequal pupils; yet there is nothing sufficiently definite in the physical 
examination to justify a diagnosis of visceral syphilis. 

Of the other causes of pain above mentioned there is not sufficient 
evidence, though only lead can be positively excluded. The most 
significant point of the physical examination is the satin-like surface of 
the skin. This quality, when well marked in workingmen, is strong 
evidence of recent alcoholism, and when, as in this case, the history 



RICHT HYPOCHONDRIAC PAIN 21 5 

does not at once suggest any such habit, the evidence obtained through 
a routine physical examination, which includes a note on the condition 
of the skin, may be most important. This is especially true when no 
other cause can be found for the sudden appearance of marked gastric 
disturbances in an adult. 

Outcome. — The patient was put on Lenhartz's diet, and in a couple 
of weeks seemed perfectly well. 

Diagnosis.— Alcoholic gastritis. 

Case 101 

A young Jewish house painter eighteen years old, who was first seen 
March 16, 1908, has had several attacks of rheumatism, but neverthe- 
less has considered himself well until five weeks ago, when he began 
to suffer from pain in the right upper quadrant, together with dyspnea 
on exertion, weakness, and cough, with frothy white sputa. For the past 
ten days he has been in bed, and found it impossible to lie down at night 
on account of cardiac distress. 

On physical examination he was found to be pale and slightly cyanotic. 
The veins of his neck were markedly distended and showed a systolic 
pulsation. The carotids also pulsated vigorously. The heart showed 
a diffuse pulsation in the second, third, fourth, and fifth left interspaces, 
but the maximum impulse was seen and felt in the sixth spac^ 1 £ inches 
outside of the nipple-line. The area of cardiac dulness extended 2\ 
inches to the right of midsternum, and the cardiac impulse could be 
felt for nearly an inch beyond the right of midsternum. The heart 
was regular; rate, no. At the apex a systolic and a presystolic murmur 
were heard. In the left axilla and along the left sternal border the sys- 
tolic murmur was much more intense, and a musical diastolic murmur 
was heard. The pulmonic second sound was much accentuated; the 
aortic second sound was absent. The pulse was of low tension and 
of the Corrigan type, but no capillary pulse was demonstrated. The 
lungs were normal except for the presence of a few moist rales at the 
of the left axilla. There was dulness in the Banks, shifting with 
change of position. The edge of the liver was felt three inches below the 
ribs. The organ was tender, and moved with each systole. The urine 
averaged 30 ounces in twenty four hours, with a specific gravity of J025. 
There was a slight trace of albumin and a few granular casts. The 
blood showed nothing abnormal. There was no fever. 

Discussion.- In relation to the prognosis and treatment of this 

it i.^ important to form some estimate of its duration. Even a 

Dry study of the cardiac lesion must convince us that the heart 



2l6 DIFFERENTIAL DIAGNOSIS 

was diseased for some time previous to the last five weeks, during which 
he has called himself sick. In view of the size of the heart and the 
character of the murmurs (which suggest stenoses and therefore chronic- 
ity) we may assume that the disease has existed for months, if not for 
years. 

Cardiac lesions involving marked hypertrophy are most often due to: 

(a) Valvular disease. 

(b) Chronic nephritis. 

(c) Adherent pericardium, with or without interstitial myocarditis. 
Renal disease may be ruled out by the low tension of the pulse and 

by the characteristics of the urine. Adherent pericardium by itself 
cannot produce so marked a diastolic murmur and would not account 
for the arterial changes (Corrigan pulse). We cannot exclude the 
possibility of adherent pericardium complicating other lesions, but 
alone it would not account for the facts. 

The signs certainly point to the existence of disease at the aortic 
valve, and probably to a similar condition at the mitral. Is the aortic 
lesion single or double? The physical signs give us assurance only of 
aortic incompetence, but postmortem experience has led me to believe 
that whenever aortic regurgitation is recognized in a cardiac case of 
considerable duration occurring in a young person, aortic stenosis is 
almost always present as well, whether the physical signs indicate it or 
not. In other words, aortic disease due to endocarditis almost always 
produces stenosis as well as regurgitation if it has lasted longer than a 
few weeks. 

As this case occurred previous to the discovery of the Wassermann 
reaction, we had no means of ascertaining whether the aortic lesions 
were possible or probably due to syphilis. 

As regards the mitral valve, we have no way of being sure whether 
or not an endocarditis has been at work there. The systolic murmur 
might be due to relative insufficiency without lesion of the valve itself, 
while the presystolic murmur might be of the type described by Austin 
Flint. But the strong accentuation of the pulmonic second sound 
gives us reason slightly to favor a definite mitral lesion. 

Obviously, there is passive congestion of the liver, explaining the 
pain and tenderness in the right hypochondrium, and these facts, 
together with the gathering ascites (shifting dulness in the flank), make 
it clear that the tricuspid valve is leaking badly. This still further 
inclines us to assume an organic mitral disease. The urine is typical 
of passive renal congestion. 

Why should the heart have begun to fail just at this time? We are 



RIGHT HYPOCHONDRIAC PAIN 217 

apt to explain such events through a so-called break of compensation 
supposedly of mechanical origin. The individual is supposed to have 
reached and overpassed the limits of his cardiac reserve power. It 
has been pointed out, however, especially by Dr. Charles Hunter Dunn, 1 
that many of the so-called breaks of compensation, occurring as they 
usually do without any known strain or overexertion, are, in fact, due to 
a fresh outbreak of the endocarditis which has previously been smoulder- 
ing upon the diseased valve. This possibility is especially to be thought 
of when the supposed break of compensation comes, as it were, out 
of a clear sky, and is accompanied by a polynuclear leukocytosis, with 
or without a slight elevation of temperature. 

Outcome. — The boy lived in the hospital from March 6th to April 
8th. At no time did he show any improvement; and despite digitalis, 
strychnin, morphin, magnesium sulphate, diuretin, calomel, squills, 
and other drugs, he died on April 8th. 

Autopsy showed fibrous endocarditis of the mitral and aortic 
valves, with stenosis and insufficiency of both. There was also a fresher 
verrucose process on both valves, and some acute degeneration of the 
myocardium. 

Diagnosis. — See last paragraph. 

Case 102 

An Irish laborer fifty-eight years old entered the hospital February 
1 8, 1908. His family history was unimportant, but he stated that for 
the past two years he had had "bronchitis," and that he had used each 
week 70 cents' worth of tobacco all his life, until eighteen months ago; 
very little since. Since the middle of October his "bronchitis" has been 
very severe, and he has felt weak and tired, but as the rest of the family 
were out on a strike, he had to keep at work. Three days ago he got 
vet through, and since then he has been in bed. He complains of 
pain in the right hypochondrium, with dyspnea and cough, especially 
when he is working. He raises yellow sputum in considerable amounts, 
but has never raised blood. Last November he was troubled for some 
weeks with pain in the left side of his chest. Two years ago he weighed 
785 pounds; now he weighs 135. Whenever he coughs he has an 
aggravation of the pain in the ri.^ht side of the abdomen beneath the 

ribs. 

Physical examination showed small, irregular pupils, which reacted 
normally. The throat was reddened and slightly swollen; the heart's 

action irregular in force and rhythm, but showing no other abnormality. 

1 1 >urin, Jour. Amer. Med. Anoc, February 9, 1007. 



2l8 DIFFERENTIAL DIAGNOSIS 

His pulses were apparently of increased tension, and his arteries easily 
palpable, but on measurement his blood-pressure showed only 120 
mm. Hg. There was no dyspnea in the recumbent position and no 
edema anywhere. The lower two- thirds of the right lung behind 
showed dulness. At the base there was intense bronchial breathing, 
with marked increase of voice-sounds and fremitus and many fine, 
moist rales. These sounds became less marked in the upper portion 
of the dull area. 

During a ten days' stay in the hospital there was no notable change 
in the physical signs. The patient had an irregular pyrexia, reaching 
as high as 102 ° F. at frequent intervals, but always falling below normal 
at some time in the twenty-four hours. 

Discussion. — Chronic bronchitis (usually with disseminated bron- 
chiectatic cavities) is the commonest cause of a long-standing winter 
cough in elderly people. The fact that this patient's cough appears 
to last all the year round does not exclude this type of bronchiectasis, 
but the fact that it is accompanied by loss of weight, by pain in the 
right hypochondrium, and by intense bronchial respiration at the base 
does not fit in well with bronchitis and bronchiectasis. The sputum 
examination is very important in solving this problem. 

The irregularity of the heart and the evidence of degeneration in 
the peripheral arteries make us wonder whether the signs at the base 
of the right lung may not represent a hydrothorax due to cardiac weak- 
ness. The signs, to be sure, are by no means typical of hydrothorax, 
but might possibly be consistent with that condition, were it not that 
the absence of dyspnea and edema points strongly against the existence 
of any cardiac weakness sufficient to account for hydrothorax. 

If w r e fix our attention upon the physical signs alone, there is much 
to suggest a pulmonary abscess, dependent either upon a postpneumonic 
empyema rupturing into a bronchus or upon some unknown cause 
(" primary pulmonary abscess ") . But the long duration of the symptoms 
and the lack of any suggestion of acute onset make this rather unlikely. 

But for the unusual position of the signs, it would be natural to 
consider pulmonary tuberculosis first of all in this case. Even as it is 
this disease is by no means to be excluded. Repeated and thorough 
examinations of the sputa are called for. 

Outcome. — The sputum showed many tubercle bacilli and also 
many pneumococci, both within and outside of the leukocytes. The 
patient remained in the hospital until the second of March without show- 
ing any considerable change in any respect, except that he gained 4 
pounds in weight. He is troubled greatly with insomnia, for which 



RIGHT HYPOCHONDRIAC PAIN 219 

he was given chloral hydrate, 15 grains, on two occasions, and veronal, 
10 grains, once. His coughing was relieved by J grain of codein, and 
his bowels were kept regular by A. S. and B. pills. After the first few 
days he was able to be up and out-of-doors, and gained considerably in 
strength. 

Diagnosis. — Phthisis. 

Case 103 

An English tailor thirty-eight years of age, who entered the hos- 
pital March n, 1908, had been complaining of pains throughout his 
body, especially in his lower legs, for the past seven weeks. The 
pains were so severe as to compel him to give up work, but were 
relieved by treatment. Three days ago he began to have pain in 
the right upper quadrant, radiating to other parts of the abdomen and 
downward. His appetite has been poor, but he has not vomited. His 
bowels have been moved by cathartics. Three days ago he had two 
severe chills, and since then he has sweat a good deal at times. 
Nothing abnormal was noticed about his water. 

Physical examination revealed nothing wrong in the chest. The 
abdomen was full, tympanitic throughout, and held rather rigidly. 
The patient appeared to suffer a good deal of pain, but when his atten- 
tion was distracted, one could palpate deeply without discovering any 
tenderness. Attempts to move the bowels were not satisfactory. The 
leukocyte count at entrance was 14,000; next day it had risen to 21,000, 
and on the third day to 25,200. His temperature ranged between 101 
and 102 ° F.; his pulse, between 90 and 100. His urine showed nothing 
abnormal. 

Discussion. — The patient's account of himself leaves us still in the 
dark as to the nature of his trouble. Discovering that his abdominal 
tenderness apparently disappears when his attention is distracted, we 
are in danger of discounting his other and more serious symptoms. 
But with pain, chills, and an increasing leukocytosis there is almost 
certainly a focus of infection somewhere. Our best guide in all proba- 
bility is the initial pain, since he has not yet arrived at that third stage 
in the development of an infection at which., after scattering itself in 
confusing radiations, the pain and tenderness finally ''settle" over 

ite of the disc, ee further discussion of this point on ]». 207.) 

There is nothing in the data here presented to incriminate the 

kidney or the stomach. On the whole, therefore, the most likely place 

for investigation Is the gall bladder. Nevertheless, there are many 

other possibilities. 1 have seen a Case much like this in which llirom- 



220 DIFFERENTIAL DIAGNOSIS 

bosis of a mesenteric artery was found at operation, but I have never 
known that diagnosis correctly made before operation. Appendicitis 
and portal phlebitis are also possible. 

Outcome. — Laparotomy on the thirty-first revealed an acute chole- 
cystitis. 

Diagnosis. — Acute cholecystitis. 

Case 104 

A Hungarian woman of sixty entered the hospital August 22, 1907, 
complaining of two months' pain in the right upper quadrant of the 
abdomen, but asserting that her sickness was wholly due to the behavior 
of her step-daughter. As a result of this the patient has lost her appetite, 
become constipated and rather sleepless, but has not given up work. 
She has had five children and no miscarriages, and has always con- 
sidered herself well. She passed the menopause twenty years ago; 
her past history and family history have been wholly good. 

On examination she was found to be decidedly pale. There was 
no glandular enlargement. There was ptosis of the left upper eyelid, 
but the eyes were otherwise normal except for marked irregularity of 
the pupils and a failure to react to light. The chest revealed nothing 
abnormal. The abdomen was large and flabby. The whole of the 
right half of it was occupied by a hard, smooth, irregular mass, immova- 
ble, not tender, and very sharp at the edge. The dulness over this 
area was continuous with the liver dulness, which began at the sixth 
rib. The lower border of the tumor was six inches below the costal 
margin (Fig. 34). There were slight edema along the shins and marked 
varicosity of the veins in both legs. 

The hemoglobin was 20 per cent.; leukocytes, 2000; the urine 
normal. Vaginal and rectal examinations were negative. The gastric 
contents extracted after a test-meal showed no free hydrochloric acid 
and no occult blood. The capacity of the stomach was 50 ounces. 
There was no residue before breakfast. 

Discussion. — The problem here is of a tumor in the right hypo- 
chondrium with anemia — a tumor which gives every evidence of being 
coarsely irregular in shape. Under these conditions the possibilities for 
diagnosis are as follows: 

(a) Liver — cancer, syphilis; much less probably hydatid, enlarged 
gall-bladder, downward displacement of the normal organ. 

(b) Kidney — tuberculosis, hydronephrosis or pyonephrosis, cystic 
degeneration, neoplasm. 

(c) Retroperitoneal tumors displacing or pushing forward the liver. 




^« 



Fig. 34. — Outlines of a mass felt in Case 104. Chief complaint is pain in the right hypo- 

chondrium. 



RIGHT HYPOCHONDRIAC PAIN 221 

Tumors of the stomach or intestine are practically out of the ques- 
tion. Masses of exudate and matted intestines, such as occur with 
tuberculous peritonitis, are smaller and have no sharp edge. 

Returning, then, to the three main groups listed above, we may 
exclude displacements' of the liver and enlargements of the gall-bladder, 
since the shape of the tumor here present does not correspond at all 
with any of these. 

Hydatid cysts of the liver do not produce so grave an anemia and 
are usually large enough to be perceptible by the individual and com- 
plained of by him before the physician discovers them. This patient 
was wholly unaware of her tumor. 

Cancer and syphilis of the liver remain as possibilities, to the dis- 
cussion of which we shall return presently. 

Of the tumors connected with the kidney, those due to tuberculosis 
are perhaps the commonest. They almost invariably produce pyuria 
and bladder symptoms, which are not present here. Further, the shape 
of this mass and its position in the abdomen are not at all characteristic 
of tumors originating in the kidney. Fever and pain would also be 
expected in a patient suffering from renal tuberculosis, though these 
symptoms are less constant than those above mentioned. 

Hydronephrosis and pyonephrosis produce smooth, rounded tumors, 
usually elastic in feel, and more deeply situated in the loin than the 
mass here in question. They often appear intermittently, their dis- 
appearance being accompanied by an increased flow of urine. 

Cystic kidneys are practically always congenital and bilateral. 
They are not associated with anemia; indeed, none of the renal lesions 
hitherto mentioned produces any considerable anemia in the great 
majority of cases. 

New-growths of the kidney may produce grave anemia, but when 
this is the case, they are practically always associated with hematuria, 
which has been absent here. 

Retroperitoneal tumors originating in the prevertebral glands occa- 
sionally present a picture much like that here seen. The fact that the 
tumor is immovable tends to identify it with a retroperitoneal structure, 
rather than with the liver. Not infrequently these retroperitoneal 
tumors displace the liver downward and forward, so that what our 
hands feel is, in fact, not the new-growth itself, but the normal liver. 
I have taken part in long and fruitless discussions as to what disease 
of the liver is present in a < ase of this Kind, only to discover at operation 
or autopsy that we have been suspecting the wrong organ. The nodular 



22 2 DIFFERENTIAL DIAGNOSIS 

surface of the growth from which this woman is suffering excludes the 
latter possibility. 

The tumor is certainly not the normal liver: it is either a diseased 
liver or a new-growth arising elsewhere. 

With these possibilities in mind we return to the general study of 
the case, and are struck by the fact that the patient has a ptosis and 
pupils unresponsive to light, both of which symptoms are characteristic 
results of old syphilis. This naturally makes us inclined to follow up 
the clue and try the therapeutic test. A course of iodid and mercury 
will do no harm to any malignant new-growth, and will probably produce 
marked improvement, local and general, if the liver be syphilitic. 

Outcome. — Under mercurial inunctions and potassium iodid, 5 to 50 
grains, the patient improved very markedly in ten days, and the size of 
the tumor rapidly decreased. Except for occasional doses of veronal, 5 
grains, and the painting of a 25 per cent, alcoholic solution of menthol 
over the epigastrium for the relief of pain, no other medication was given. 

Diagnosis. — Hepatic syphilis. 

Case 105 

A Russian Jewess of forty-two has been complaining for eighteen 
months of a burning pain in the right upper quadrant, almost constant, 
often keeping her awake, sometimes shifting into the back, but never 
colicky or paroxysmal. She has vomited occasionally, but has never 
been jaundiced. For the same period she has had distress across the 
upper half of the abdomen after meals, with belching and constipation, 
her bowels moving only every four or five days. For three months all 
these symptoms have been aggravated, and she has vomited green 
material nearly every day. She has never vomited any blood or any 
food. She thinks she has lost much weight. She has no appetite 
and has been in bed much of the time of late. 

The patient was obese, the chest negative, the abdominal wall loose, 
flabby, and soft. The right kidney could be felt at three fingers' breadth 
below the ribs, and the edge of the liver was also palpable. Physi- 
cal examination, including the blood, pulse, temperature, respiration, 
and blood-pressure, was normal. The urine ranged between 25 and 35 
ounces in twenty-four hours, with a specific gravity from 1012 to 1019; 
there were very slight traces of albumin and a few hyaline, granular, 
and brown granular casts. Examination of the stomach-contents and 
of the stools revealed nothing abnormal. 

Discussion. — When a Russian Jew complains of a "burning pain," 
it usually turns out, en closer questioning, that he has a burning and 



ri.;ht hypochondriac pain 223 

not a pain. The word "burning" (brennend) is used by the Jews far 
more often in describing their symptoms than by any other race, and, as 
a rule, patients who use this term turn out to be free from organic disease. 
Whether it is a cutaneous paresthesia connected with nervous debility, 
or whether it is connected with gastric stasis and fermentation, is often 
very difficult to determine. 

Gastric symptoms appearing for the first time in a person over forty 
always make us think of cancer of the stomach, but if that disease had 
existed for eighteen months, we should be almost certain to find stasis, 
emaciation, or anemia. Peptic ulcer cannot be positively excluded, 
but the symptoms are not definite enough to warrant our beginning 
treatment for that affection until more probable alternatives have been 
tried out. 

The palpable kidney and the presence of albumin and casts in the 
urine make it our duty to consider whether the symptoms may be due 
to some form of renal disease. These symptoms could be produced by the 
kidney if the latter exerted direct pressure upon the pylorus or intestine, 
so as to retard their movements in the course of digestion. But this 
seems very unlikely in view of the moderate size and free mobility of 
the organ. The kidney might also be responsible for suffering like 
that here described if it were the seat of a chronic nephritis with uremia, 
but the normal condition of the heart and blood-pressure makes this 
unlikely, and the urine is not at all typical of acute nephritis. 

Evidently the patient has a general visceroptosis, and this, with 
her obesity, her incompetent abdominal muscles, and her constipation, 
might well be sufficient to account for her complaints. 

It may be well to say a word here about the psychic significance 
of green vomiting. Of course, every physician is aware that, from 
the physical point of view, any long-continued or violent vomiting 
produces green-colored vomitus through the compression exerted upon 
the gall-bladder by the abdominal walls. But in the patient's mind 
□ vomiting has often a dark and terrifying significance, so that 
ell explicitly to reassure any patient who complains of this symptom, 
remembering that he docs not share our understanding of its harm- 
Outcome. A snugly fitting abdominal bandage gave the patient 
marked relief, and when her bowels had been regulated by the 
of calomel, ' grain every fifteen minutes until ten doses, followed 
in half an hour by a seidlitz powder and thereafter by cascara, she was 

ah' • the hospital, mu< h relieved, ;it the end of two wccl 

Diagnosis. Hansebauch. 



224 DIFFERENTIAL DIAGNOSIS 

Case 106 

A carpenter of fifty-four entered the hospital June 19, 1908, with 
the statement that six weeks ago, while at work, he had a sudden attack 
of pain in the right upper quadrant, radiating to the right shoulder. This 
pain was relieved by a hot drink, and disappeared in about three hours. 
He vomited once that night. He went to work the next morning. A 
week later the pain returned, and it has since been nearly continuous, 
though for the past two days it has been less severe. At the onset it was 
accompanied by a swelling of the abdomen and by jaundice. He 
has had dark urine, light stools, and much itching for the past five 
weeks. Fever and vomiting have been absent. His appetite has been 
poor, and he has had moderate constipation. 

On examination, moderate jaundice and marks of scratching were 
everywhere evident. The chest was normal. The abdomen showed 
tenderness in the epigastrium and for several inches to the right of this 
point. The upper right rectus was more resistant than the left. The 
edge of the liver could be felt an inch and a half below the rib margin. 
The patient has lost 42 pounds in the past eight weeks. 

Discussion. — The diagnostic problem confronting us concerns the 
cause of emaciation, jaundice, steady pain, and enlargement of the liver 
in a man of fifty-four. Cancer of the pancreas or of some portion of the 
bile-ducts would produce all these symptoms, and is their commonest 
cause in men of this age, but it is hard to understand why any of these 
lesions should produce so sudden an attack of pain and of jaundice. 
The supposed cause — cancer — being an affair of gradual growth, one 
would expect the symptoms to develop gradually, not suddenly. Never- 
theless, clinical experience has shown that cancer may manifest itself 
suddenly, and with the symptoms here described. We must face the 
fact, whether we understand it or not. Against cancer is the ab- 
sence of an enlarged gall-bladder, which is the rule when cancer 
obstructs the bile-ducts. But this objection is not sufficient to make 
us certain that cancer is not present. The possibility must still be 
entertained. 

Stone in the common duct might produce all the symptoms under 
discussion, and would account, better than cancer does, for the sudden 
onset and the biliary colic. The loss of 42 pounds in eight weeks as 
a result of cholelithiasis alone is at first sight astounding, but experience 
shows that it is not at all unusual. More unexpected is the absence 
of fever, chills, vomiting, and of variations in the intensity of the jaundice, 
all of which are the rule when a stone blocks the common duct. The 



RIGHT HYPOCHONDRIAC PAIN 225 

moderate degree of jaundice, on the other hand, favors stone rather than 
cancer. 

Obliteration of the bile-ducts by the scar of an inflammatory process, 
due to syphilis or some other cause, is a very rare lesion. It is usually 
gradual in onset and does not produce sharp pain. 

Nothing is said in the history about the patient's habits. If we 
choose to assume that he was a confirmed alcoholic, his jaundice might 
be due to cirrhosis of the liver, especially as the edge of that organ is 
easily palpable. The sudden pain, however, could hardly be due to 
cirrhosis, and, as the case stands, we have nothing to support such a 
hypothesis. The habits should be further investigated. 

On the whole, the diagnosis must remain in doubt as between stone 
and cancer, the odds slightly favoring stone. 

Outcome. — On the twenty-second of June the abdomen was opened 
and two large stones were removed from the common bile-duct. The 
patient made an uneventful recovery. 

His itching was relieved by a powder consisting of sodium salicylate, 
talc, and starch in equal parts, dusted on the skin, and also by an alkaline 
bath. 

Diagnosis. — Stone in ductus choledochus. 

Case 107 

An unmarried woman of twenty-nine entered the hospital March 
11, 1908. Since the age of sixteen she has had at times "stoppage of 
the bowels," worse when she is on her feet. When questioned as to 
the nature of this stoppage, she stated that it consisted of pain in the 
right upper quadrant, so severe that she cannot stand the pressure of 
her clothes, accompanied by the presence of a lump which is more 
.prominent when she exercises. This trouble has been especially bad 
for the past five months. Her bowels rarely move without medicine, 
and her stools are small, hard, and often black. She has a poor appetite, 
but never vomits. She had considerable cough and sputa off and on for 
years, but has never raised blood. For four months she has had much 
dyspnea and palpitation. Her urine is at times scanty, never bloody, 
and never passed in large amounts. She has lost five pounds in the 
last two years. 

The patient is pale (hemoglobin, 75 per cent.). Scattered on the 

light half of the trunk and the inner aspect of the right Upper arm are 

numerous light-brown, irregularly shaped spots. The glands arc 

ible in the axillae and groins. The tongue is bat shaped -widest 

at the tip. it is protruded very far, and during this act the anterior 



2 26 DIFFERENTIAL DIAGNOSIS 

pillars of the fauces are drawn forward. A low-pitched systolic murmur 
is heard over all the precordia, but not transmitted beyond that area. 
The heart shows no enlargement. The pulmonic second sound is 
greater than the aortic second. In the epigastrium a violent pulsation, 
vertical and lateral, is felt, raising the hand three-quarters of an inch 
at each beat of the heart. Beneath the margin of the right ribs a 
smooth, rounded mass, about four inches long and two inches wide, 
can be grasped between the hands and moved about in all directions. 
It is very tender. 

Discussion. — The points deserving discussion in this case are the 
nature of the "stoppage of the boweis," the interpretation of the heart 
murmur in connection with the patient's dyspnea and palpitation, the 
significance of the way in which the tongue is protruded, the nature 
of the rash upon the chest, and the importance of the mass in the right 
hypochondrium. 

It is clear that she has no stoppage of the bowels. We have to 
explain, however, why the lump complained of in the upper right quad- 
rant and the pain which accompanies it are more prominent on exer- 
tion. This is the case not infrequently with a tender, passively congested 
liver, the result of cardiac insufficiency. But have we any such insuf- 
ficiency in this case? 

Since the heart is not enlarged and the pulmonic second sound no 
louder than we should expect it to be in a woman of twenty-nine, we 
have only the murmur to suggest heart disease. But from a systolic 
murmur alone it is never wise to infer the presence of any disease of 
the heart, especially when the patient is anemic. It seems reasonable 
to consider this murmur as hemic or functional. We have no reason, 
then, to believe that the heart is failing or that the lump in the right 
upper quadrant has any relation to it. 

A patient who protrudes his tongue in the way described above, 
so that the whole of it can be seen, has usually been in the habit of 
looking at his tongue in a mirror. The pillars of the fauces are then 
drawn forward by the effort to get the tongue completely into the outer 
world. These facts give us a certain inkling of the patient's mental 
condition and of its possible bearing on the interpretation of his symp- 
toms. 

The eruption here described seems to correspond with that produced 
by tinea versicolor. Though other possibilities are open, this seems 
the most reasonable one, provided the lesions are of long standing. 
This is the most common position for an eruption of that origin. 

The mass in the right hypochondrium corresponds accurately to 






RIGHT HYPOCHONDRIAC PAIN 227 

the description of a floating kidney, though not all such kidneys are 
tender. It is probably the lump which the patient felt at the times when 
she supposed herself to have stoppage of the bowels. This would 
account for its greater prominence when she is on her feet. 

The association of floating kidney with a great variety of so-called 
neurasthenic symptoms is a very familiar fact clinically. That this 
patient is of a neurotic temperament is suggested by the violent beating 
of the abdominal aorta (dynamic aorta), by the way she puts out her 
tongue, and by her chronic constipation. In the absence of any other 
lesions discoverable on physical examination the diagnosis of floating 
kidney associated with slight anemia in a neurotic person seems the best 
explanation of the symptoms. The dyspnea may well be due to the 
anemia. 

Outcome. — The patient was given a close-fitting abdominal binder, 
which apparently gave--much relief. Reassurance and general tonic 
treatment (Blaud's pill, 10 grains thrice daily, tincture of nux vomica, 
10 to 50 drops before each meal) played a large part in her recovery. 

Diagnosis. — Debility; floating kidney. 

Case 108 

An American woman of forty-six has been doctoring for stomach 
trouble for five months. A month ago she was taken suddenly with a 
profuse black, watery diarrhea. This was followed by vomiting, chills, 
and pain in the epigastrium and back. For a week she was kept more 
or less under opium, after which the gastric and intestinal symptoms 
abated, but she has remained in bed most of the time since then, in a 
very exhausted condition, and suffering most of the time from pain in 
thr right upper quadrant and in the small of the back. This pain is 
constant, with occasional exacerbations. Opium has frequently been 
'given. For several weeks she has taken only liquids. Although the 
pain appears only in relation to eating, she vomits nearly every day at 
irrre^ular intervals. She has never vomited blood, and has never been 
jaundiced. She has had a slight cough for five years, and dyspnea 
on exertion for one year. She has lost 13 pounds in the past two years. 
The pain is often severe enough to keep her awake at night. 

On physical examination the mucous membranes are found pale, 
chest is negative, except for slightly diminished respiration in the 

righl back, below midscapula. The abdomen is entirely negative, except 

that the edge of the liver is palpable on deep inspiration. 

The blood shows red cells, 4,032,000; white cells, 6X00; hemoglobin, 

55 per cent. 



2 28 DIFFERENTIAL DIAGNOSIS 

The stained smear shows some achromia and poikilocytosis. The 
differential count and the other features of the blood are normal. Care- 
ful examination in a warm bath, with complete and satisfactory relaxa- 
tion of the abdominal muscles, shows absolutely nothing abnormal. 
Examination of the stomach shows no fasting contents. The gastric 
capacity is 36 ounces — the lower border of the organ one inch below 
the nave! after inflation. After a test-meal no free hydrochloric acid 
and no organic acids are found. The guaiac test is negative in the 
gastric and intestinal contents. 

After three weeks' stay in the hospital the patient gained three pounds, 
but continued to complain of pain and seemed very miserable. 

Discussion. — The black color of the stools, associated with a long- 
continued gastric disturbance, forms an important portion of the picture 
of peptic ulcer. We must remember, however, that as she has been 
doctoring for stomach trouble for five months and has taken a great 
deal of opium, it is quite possible that her symptoms may be due wholly 
or in part to the treatment. Black stools may well be due in this case 
to that commonest of gastric medicaments, subnitrate of bismuth. In 
patients who have been through five months of this kind of treatment 
it is not at all surprising to find hydrochloric acid absent from the gastric 
contents. Her stomach empties itself normally, shows no enlargement 
and no blood. One more point serves to increase our confidence that 
no visceral, disease is present, namely, the complaint of a year's dyspnea 
by a patient whose heart and lungs are normal. This dyspnea ante- 
dates the occurrence of stomach symptoms by at least seven months. 
This would be quite natural if we supposed that the dyspnea and the 
stomach symptoms were alike due to the anemia shown by the present 
blood examination. If, on the other hand, the anemia resulted through 
hemorrhage from an ulcer, the dyspnea should not have antedated the 
stomach symptoms. 

Yet, after the use of treatment based upon the idea that anemia was 
the cause of her symptoms, there was no clear proof that we were right 
and it seemed best to explore the abdomen. 

Outcome. — Operation by Dr. F. B. Harrington revealed absolutely 
nothing, but the patient seemed greatly improved after it, and when 
last heard from had continued in good health. Cases of this type 
should be borne in mind when discussion arises regarding those opera- 
tions for "chronic appendicitis" in which the appendix shows signs of 
appendicitis only to the eye of the surgeon, while the pathologist remains 
unconvinced. 

"But the patient's symptoms abated after the operation," says the 




Fig. 35. — Diagram of bulging and resistance as recorded in Case 109. Symptoms, pain 
over the above area, weakness, dyspnea, and cough. (See also Fig. 36.) 




Fig. 36.— Signs discovered in the back of patient described on page 229. (See also Fig. 35.) 



RIGHT HYPOCHONDRIAC PAIN 22Q 

surgeon. True, but so they did in the case just described, though 
nothing was removed. There is abundant experience to prove that 
operations and postoperative hygiene (mental and physical) are in 
themselves enough to produce a marked improvement in the symptoms 
of many a patient. 

Diagnosis. — Debility. 

Case 109 

March 18, 1907, I examined a Russian tailor thirty-nine years old, 
with the history of pain in the right upper quadrant lasting fifteen 
weeks, accompanied by frequent dry cough, shortness of breath, and 
increasing weakness, but no fever, so far as he knows. For the past 
two weeks he has had night-sweats, tenderness in the left shoulder, 
and inability to sleep on the left side. He has lost weight and strength, 
but has worked irregularly until two weeks before entrance. His 
previous history, family history, and habits are otherwise excellent. 

Examination showed a sallow, emaciated, worn-looking man. 
Nothing abnormal was detected in the examination of the heart. In 
the right back there was dulness below the angle of the scapula, with 
diminished breath and voice-sounds. The condition of the abdomen 
is best explained by Fig. 35. 

The patient's temperature ranged for eight days between 99 ° and 
ioi°F. His red cells were 4,000,000; white cells, 11,000; hemoglobin, 
60 per cent. The stained smear showed nothing abnormal. The urine 
was equally blameless. In the stools numerous eggs of the Trichuris 
trichiuria were found. Rather large, palpable glands were found above 
both clavicles; the chest, head, and extremities negative, except as 
above noted. Free purgation produced no change in the physical signs. 

Discussion. — There is a good deal to suggest phthisis in the first 
impression of this ease — cough, dyspnea, weakness, night sweats. 
But though there are some abnormal signs in the right back, they are 
sufficient to account for the symptoms. Empyema is, perhaps, 
more likely, but I have ncvei heard of an empyema which worked to 
the surface so near the ensiform cartilage. It is unfortunate thai an 
v ray was not taken, owing to the patient's great prostration. By this 

means one might have obtained some evidence as to whether the trouble 
below the diaphragm. Our attention naturally centers 

on the region of the prominence shown in Fi '. 35; at first sight the 
Certainly appears to be below the diaphragm. 

mors of the liver should first engage attention. Cancer of the 

liver almo :.resent-, itself in this situation only. We find almosl 



230 DIFFERENTIAL DIAGNOSIS 

invariably a general enlargement of the liver downward, and multiple 
nodular masses below the ribs. I have never known a hepatic cancer 
to produce a localized bulging of the chest-wall such as was present in 
this case. This latter observation applies also to tumors of the colon, 
gall-bladder, retroperitoneal glands, and kidney. The hypothesis of 
cancer somewhere receives some support from the presence of enlarged 
glands over the clavicle, which might represent metastases; but it is 
very hard to see where the cancer could be situated. 

Hydatid cyst of the liver was much discussed in the numerous bed- 
side consultations over this case, but it was pointed out that hydatid 
does not produce so much prostration and pain, not, at any rate, until 
it has produced a tumor much larger than that in this present case. 
The striking thing about most hydatid cysts of the liver is the slight 
impression that they seem to make either upon the patient's conscious- 
ness or upon his general health and nutrition. The feel of the tumor 
in this case is not at all characteristic of hydatids. 

Can local disease of the chest- wall explain these symptoms? Tuber- 
culosis, syphilis, actinomycosis, or neoplasm might appear at this point, 
but they should involve the ribs or intercostal tissues themselves, whereas 
in this case the ribs seem to be quite unaffected — merely pushed forward 
by something behind them. 

Hepatic abscess or subdiaphragmatic abscess often causes a promi- 
nence at exactly this point, and some of the symptoms of the case — the 
pain, cough, dyspnea, weakness, and night-sweats — could be thus ex- 
plained. On the other hand, we have no history of the ordinary causes 
for either of these varieties of abscess — no dysentery, no appendicitis, 
no peptic ulcer or gall-stones. It seems remarkable, moreover, that 
the leukocytes should not be more increased if there is an abscess large 
enough to produce such a tumor. Despite these objections, however, 
the picture corresponds more nearly with that of subdiaphragmatic 
abscess than with any other disease. 

Outcome. — A week later the patient's abdomen was opened and a 
subdiaphragmatic abscess found. Its source remained doubtful. 

Diagnosis. — Subdiaphragmatic abscess. 

Case 110 

A fireman of fifty-eight worked on the Panama canal in 1904 and 
1905, but had to return in December, 1905, on account of a long 
attack of dysentery. Though always a heavy drinker, he was other- 
wise well until May, 1906, and then weighed 212 pounds. In May 
irregular colicky pains began in the right upper quadrant, which were 



RI3HT HYPOCHONDRIAC PAIN 



231 



much worse at night and which did not, as a rule, bother him in the 
day-time. At times he suffered enough to require morphin. There 
was no radiation and no vomiting, but there was nausea, and consider- 
able relief was obtained by belching gas. The bowels were rather 
loose, and a movement caused relief of pain. At times the movements 
were clay colored; at other times they were brown. About June 1st 
the stools became persistently clay colored, the skin was noticed to be 
yellow and the urine dark colored. 

From June 1st until the present time (August 8th) he has had no 
pain, but to-day about noon he suddenly began to have a series of very 
severe cramps, vomited for the first time, and had a 
chill. His present weight is 161, a loss of 50 pounds, 
but he had been able to work until six weeks pre- 
viously. 

Inspection of the patient's body revealed nothing 
abnormal except intense jaundice, with brownish mu- 
cous membranes and an increase of liver dulness, such 
that the organ extended from the fifth rib in the 
nipple-line to a point one inch below the costal margin. 
Below this edge a soft, rounded mass could be made 
out, about the size of a lemon. The spleen was not 
palpable. The white cells were 16,600; hemoglobin, 
90 per cent. The Cammidge test was positive. In the 
afternoon after entrance the patient suddenly sat up in 
bed and yelled with pain; it was referred to the epi- 
gastrium, and was, he said, unlike any that he had had 
before. The abdomen was now rigid throughout, with 
marked tenderness, especially in the epigastrium. The 
patient vomited several times this afternoon. 

Discussion. — A history of dysentery and a residence in the tropics, 
when followed by symptoms which appear to involve the liver, should 
always remind us that hepatic abscess is a common complication of 
tropical dysentery. This idea seems all the more plausible in the 
present case, because there have been chills, fever, leukocytosis, and an 
increase of liver dulness. Yet the pain of hepatic abscess could rarely 
scribed as "cramps." The disease is often painless; if there is 
any pain at all it is usually a steady, dull, but increasing type. The 
soft tumor below the ribs, moreover, cannot be due to hepatic abscess, 
and we do not expect such intense and persistent jaundice as the 
• of that dise 

The colicky pains and the jaundice might well have been due to a 




Fig. 37. — Chart of 
case no. 



232 DIFFERENTIAL DIAGNOSIS 

stone in the common duct. Had this stone been near the entrance of the 
cystic duct, infection might well have extended to the gall-bladder. 
Suppurative cholecystitis and final perforation of the gall-bladder would 
then account for the chill and intense pain on the day of entrance. 

Against this we have the fact that a gall-bladder which has previously 
nourished stones is not often so distensible as to form a tumor, such as 
projected below this patient's liver. The intensity and steady persistence 
of the jaundice are also somewhat unusual for choledochus stone. 

Cirrhosis does not seem probable, though the usual cause of that 
disease appears to have been operative. A pain like that here described 
is rarely if ever due to cirrhosis, and the jaundice which occurs in a 
certain proportion of cirrhotic cases is almost never intense. Cancer 
of the pancreas or of the bile-ducts is the commonest cause of intense 
and persistent jaundice in a man of this age. The tumor below the 
ribs might be the enlarged gall-bladder which generally results from 
this disease. On the other hand, the pain is severer and more sudden in 
its onset than is to be expected in cancerous obstruction of the bile- 
ducts. The colic and the variation in the color of the stools seem more 
like cholelithiasis. No one of these facts, however, excludes cancer, 
which seems, on the whole, the most reasonable diagnosis. 

How are we to explain the chill and attack of pain described in the 
last few lines, which are intended to convey an idea of the greatest 
possible severity, of suffering? In my experience an abdominal pain 
of this description, such that the patient suddenly yells out in agony, is 
almost always due to one cause — perforative peritonitis. This might 
be accounted for under either of the diagnoses last discussed; either 
stone or cancer may have caused ulceration of the ducts and set up at 
first a localized peritonitis, which later perforated and set free a virulent 
fluid into an unguarded peritoneum. 

Outcome. — He died three days later. The variations of his tem- 
perature are shown in the accompanying chart. He was able to take 
very little food, and during the last twenty-four hours was delirious. 
Autopsy showed cancer of the head of the pancreas, almost occluding 
the common bile-duct. The pancreas was practically destroyed. The 
gall-bladder was enlarged, much distended, not inflamed, and con- 
tained a single gall-stone. There was an extensive cancerous infiltra- 
tion of the posterior wall of the stomach. There was also an acute 
general peritonitis, for which no cause could be found I 

Diagnosis. — Pancreatic cancer. 






RIGHT HYPOCHONDRIAC PAIN 



233 



Case 111 

A negro of thirty-five has complained of steady pain in the right 
hypochondrium for two months. This pain came immediately after 
eating and lasted about two hours. His appetite is good. His bowels 
are constipated, moving only once in from two to seven days with 
medicine. He has also suffered from numbness and tingling in his legs, 
with weakness, and has had a cough for the past two weeks, with slight 
white sputum. 

Physical examination shows an irregular fever (see chart), the skin 
very dry and scaling, the heart not remarkable, the lungs negative. 
There is a nodular mass indistinctly felt in the 
right iliac fossa, tender, but at times difficult 
to outline. The abdomen is retracted, and 
peristalsis can be seen near the navel. On 
the left hand and the dorsum of the right 
foot are elevated areas of reddened skin, with 
a pink, smooth center, about one inch in diam- 
eter. The chest is negative; likewise the 
blood and urine. 

Examination of the stomach by means of 
a stomach- tube showed that the organ would 
hold about only 23 ounces of water without dis- 
tress. Its lower border after inflation reached 
just below the navel. The contents extracted 
after a test-meal showed free HC1, 0.1 per 
cent.; no occult blood; no lactic acid. No 
contents could be obtained from the stomach 

. P , , e Fig. 38. — Chart of case in. 

before breakfast. 

Discussion. — There is no need of extended discussion here. A 
nodular mass in the right iliac fossa, accompanied by visible peristalsis, 
marked constipation, and fever, means chronic intestinal obstruction 
in the region of the cecum. Obstruction at this point is practically 
never due to fecal impaction alone; there is almost always some stricture 
of the gut behind which feces accumulate. Such a stricture might be 
syphilitic, cancerous, or tubercular. Occasionally a chronic appendicitis 
with adhesions produces obstruction. 

Imagine that an abscess has occurred earlier in the history of the 

this may later have,- become walled off and massed into a tumor 

something like that here felt. The adhesions associated with it might 

then lead to the symptoms of obstruction here described. 



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234 DIFFERENTIAL DIAGNOSIS 

A retracted abdomen and an irregular fever without leukocytosis is 
distinctly more suggestive, however, of tuberculosis. 

If the stricture is tuberculous, the tumor mass is probably made up of 
caseating glands adherent to the cecum, itself infiltrated by tuberculosis. 
The fact that the patient is a negro and the presence of fever — especially 
fever of the type shown in this chart— make tuberculosis more probable 
than cancer. Syphilis rarely produces so large a mass in this region. 
Extensive syphilitic infiltrations are generally found near the rectum. 
The diagnosis of pericecal tuberculosis is further supported by the 
character of the cutaneous lesions, which are distinctly suggestive of 
tuberculosis. 

No good reason can be given why the pain is referred in this case to 
the right hypochondrium, rather than to the region of the tumor, as is 
the rule in such cases. 

Outcome. — The patient remained ten days in the ward, complain- 
ing continually that he did not receive enough medicine, but showing 
no improvement in any respect. At the end of that time the abdomen 
was opened and showed a nodular mass of tuberculosis in the cecal 
region, with general adhesions but without fluid. At death, a month 
later, tuberculosis was found also in the lungs, adrenal glands, lymph- 
glands, skin, and in almost every other organ. 

D i a gn o s i s . — Pericecal tuberculosis. 

Case 112 

A young farmer of twenty-five, whose father had died of tuberculosis 
but whose family history was otherwise good, came to the hospital 
January 25, 1906, with the following story: For the past fifteen years 
he has had from time to time pain in the right upper quadrant, in attacks 
lasting from three to five days, then gradually subsiding but leaving 
him much used up. For the past three years the pain has been so sharply 
localized that it could be covered with one finger. 

Up to one year ago he averaged about two attacks a year, but within 
the past year the attacks have been from one to four weeks apart, appar- 
ently depending upon the performance of heavy work or the eating of 
hearty food. During these attacks the pain is not constant, but comes 
in spasms and is relieved by taking a "pain-killer" and using a hot- 
water bag, or by leaning over the back of a chair so as to bring strong 
pressure to bear upon the painful spot. In the last attack the pain 
radiated to the back, but never to any other point. Three years ago 
he thought he noticed in the region of the pain a bunch, which was 
tender, but gradually disappeared. The painful spasms last from 



RIGHT HYPOCHONDRIAC PAIN 235 

fifteen to twenty minutes each. He was very sallow three years ago, 
and thinks he has been so since then. His severest attacks are accom- 
panied by chills and fever. During the past year he has been able to do 
only very light work. He occasionally vomits during an attack, the 
material being usually greenish. During an attack he has nightly 
emissions. Walking on hard pavements or hard floors, especially dur- 
ing the time of an attack, causes pain in the right upper quadrant, and 
sometimes shortness of breath. His appetite between attacks is always 
good and his bowels are usually constipated. In the fall of 1905 he 
weighed 185 pounds. Now he weighs 165 pounds. Work that requires 
stooping or heavy lifting will often bring on an attack within two or 
three hours. 

Physical examination showed no jaundice. There was nothing 
abnormal in the chest or abdomen, and nothing wrong with the blood 
or urine. After staying four days in the hospital entirely free from 
symptoms he was discharged. 

May 24, 1907, he entered the hospital for the second time, and 
stated that, since leaving the wards fifteen months previously, he had 
had many attacks of pain similar to those previously described. His worst 
attack was ten months ago, when the pain failed to yield to morphin 
or chloroform, and lasted four hours. For a week after this he was 
unable to leave his bed. This spring he had nearly steady pain for the 
or six weeks following the ingestion of a large quantity of maple syrup. 
After an attack his urine is always high colored, almost black; the color 
of his stools is not abnormal. 

As on a previous occasion, physical examination was entirely nega- 
tive, but this time the use of a stomach-tube revealed that the percentage 
of free hydrochloric acid after a test-meal was o.j<), and that in the 
fasting contents the percentage of hydrochloric acid was 0.23. There 
was no reaction to guaiac in stools or gastric contents. 

Discussion. — There is much to make us think of gall-stones in 

this case, though the age and sex are against this diagnosis. The 

iatian of Buch a pain as is here described with chills and lexer, 

with deep discoloration of tin; urine, which may well have been due to 

bile, and with a bunch which niav have hern the gall bladder, goes tar 
inplete the clinical picture of cholelithiasis. This picture becomes 

still dearer as we note the freedom from digestive symptoms between 
the attacks of pain. Moreover, it may be that on stooping he shifts 

the position of .1 stone in the -/.ill bladder in such a way that it becomes 

impacted and produces colic 

B t this trouble has been going on for fifteen years, and ".ill stones 



236 DIFFERENTIAL DIAGNOSIS 

are practically unknown in a boy of ten, which was the age of our patient 
at the beginning of his attacks. Again, it is difficult to see why a gall- 
stone colic should not be relieved by morphin or by chloroform, and 
why it should not produce tenderness in the region of the gall-bladder. 
Patients who have had many attacks of gall-stones almost always ex- 
perience some of the typical radiations of the pain, which, with one 
exception, have been wholly lacking here. The absence of jaundice 
and enlarged gall-bladder adds a certain weight to the arguments already 
adduced against gall-stones. 

Next to gall-stones, by far the commonest cause of symptoms like 
these is peptic ulcer, gastric or duodenal. The long history of his 
attacks and the gradually shortening intervals between them, the excess 
of hydrochloric acid in the gastric contents, and the relief of pain by 
pressure are facts tending to convince us that peptic ulcer is present. 
On the other hand, it is curious that we were unable to obtain any 
reaction to guaiac in the gastric contents or in the stools. Why the pain 
should be increased by walking on hard pavements or hard floors, and 
why the attacks should be associated with nocturnal emissions, are 
problems not explained by any knowledge that I possess. 

A "high" (undescended) appendix comes to our minds as a possi- 
bility, but who ever saw a case of appendicitis — high or low — in which 
the pain was relieved by strong pressure, as in this case? 

Outcome. — On May 29th the abdomen was opened; a duodenal 
ulcer was found. It had perforated and become adherent to the gall- 
bladder. In connection with the relief of pain by pressure in this case 
I recall a case of duodenal ulcer which I saw with Professor Osier at 
Oxford in the summer of 1908. The man told us, without a ghost of 
a smile, that the pain was so bad that his wife often had to kneel on 
his stomach for half the night. 

Diagnosis. — Duodenal ulcer (local peritonitis). 

Case 113 

A single woman of thirty-seven entered the hospital on July 20, 1906. 
Up to the age of five years she was subject to convulsions with loss 
of consciousness, but these have not recurred since. She had diph- 
theria with paralysis of the palate at the age of twelve. In 1892 she 
fell in a gymnasium and hurt her back, since which time she has done 
no work, and has suffered from severe pain in the middle of the back 
and on the top of her head. At times she has a sense of constriction in 
her throat. She consulted an orthopedic specialist in 1902, and has 
since then worn a brace for her back off and on, with very little relief. A 



RIGHT HYPOCHONDRIAC PAIN 



237 



spur was removed from her nose one year ago. Three weeks ago she 
began to have very severe pain over the right side of the face, and was 
operated on for disease of the antrum, but none was found. -Her pain 
was immediately relieved, and sleep induced by the subcutaneous injec- 
tion of sterile water. 

Since that time she has suffered especially from pain in the right 
hypochondrium — worse in the early morning, somewhat relieved after 
the morning urination or by vomiting. 

Physical examination shows rigidity of the abdomen with marked 
sensitiveness of the right half of the head and of the back, especially 
in the dorsal region. The internal viscera, the blood and urine are 
normal, likewise the temperature and pulse. Respiration ranges 
between 30 and 45. She is often awakened by spasmodic pain in the 
neck, much increased by attempts to walk. She looks well, but still 
complains "of soreness in the bowels, which prevents her from eating 
and causes her to vomit and her head to ache." 

Discussion. — We get a strong impression, on reading this case, 
that we are dealing with nervous invalidism reinforced and made more 
obstinate by a variety of meddlesome treatments. But in any case which 
gives us this first impression we should do our best to combat it by 
endeavoring to establish the existence of some form of organic disease. 
Only in this way can we avoid doing serious injustice to many patients 
who have both organic disease and a nervous make-up, with the latter 
in the joreground. One of the problems which first engaged our 
attention was this: Why should her pain be relieved after the morning 
urination? This combination of symptoms is not at all unusual, and 
in my experience it signifies that the pain has resulted from gaseous 
distention of the colon, which is relieved when the emptying of the bladder 
shifts the pelvic tensions enough to allow the escape of intestinal gas. 

The unilateral distribution of sensitiveness over the head and trunk, 
the relief of pain by the subcutaneous injection of sterile water, the 
rapid respiration, and the history of her medical fortunes justify us, I 
think, in believing that our negative physical examination represents 
the truth, and that we are justified in making that dangerous diagnosis, 
ria. But it is only by experimental therapeutics, that is, by trying 
out the results of treatment based on the hypothesis that we are dealing 
with habit pain and nervous invalidism, that we can get any further 
certainty upon the diagnosis. To such experiments, accordingly, we 

addressed ourseh 1 

Outcome. Under a combination of scolding, encouragement, and 

[Cation she was able, at the end of a month, to walk fifteen yards 



238 



DIFFERENTIAL DIAGNOSIS 



without support. Two weeks later she could walk an eighth of a mile, 
and the pain in her head was much relieved. She still complained, 
however, of soreness in the bowels, and this she has had at intervals ever 
since that time, especially when she gets run down. 

This case seems to me to illustrate well that fallacy about the impor- 
tance of " reflex causes " for general nervous disturbances which had so 
strong a hold on the last generation of medical men. The wonder is 
that this patient escaped without appendectomy and hysterectomy. In 
many clinics she would also have undergone a gastro-enterostomy. I 
think the opinion is coming to prevail that when the history and the 
phvsical signs point strongly toward a general neurosis, attention to so- 
called reflex or local sources of irritation not only does no good, but 
makes the patient distinctly worse by concentrating his attention upon 
the part, by increasing the period of invalidism, and by withdrawing 
him from the normal supports and stimuli of the working life. 

Diagnosis. — Hysteria minor. 

Case 114 

A Portuguese tailoress, forty years old, entered the hospital December 
21, 1908. When a little girl in Portugal she had typhoid fever. In 
the preceding June she was in bed for a week with "malaria," and has 
not been well since. She has now had fever for five weeks. She has 
been at work for the first two weeks of this time, but has had headache, 
anorexia, vomiting, diarrhea, and cough for most of the time in the last 
five weeks. She has been in bed for ten days. 

Physical examination shows no emaciation. Many fine rales are 
scattered over both chests, and a few squeaks distributed among them. 
Whichever side she lies on appears to contain the greatest number of 
rales. There is a slight cyanosis, with movements of the nostrils as she 
breathes. Voice-sounds are slightly increased at the right base. The 
white cells are 6800, 56 per cent, of them being polynuclear. Widal 
reaction positive. The spleen was palpable on full inspiration. 

On the fourth of January she was suddenly seized in the night with 
sharp pain in the right upper abdominal quadrant, accompanied by 
vomiting, sweating, and a weak, rapid pulse. Despite \ grain of mor- 
phin and -^ grain of strychnin, the pain and vomiting persisted. Next 
morning there was distinct tenderness over the seat of pain, and a tender, 
rounded mass was vaguely felt in the region of the gall-bladder. 

The white cells, January 5th, were 12,800 at 10 A, M., 23,600 at 9 
p. m.; 22,800, January 6th at 9 a. M. There was still no abdominal 
spasm. 



RIGHT HYPOCHONDRIAC PAIN 



239 



Discussion. — This patient has a fever of long duration. In tem- 
perate climates, as I have elsewhere shown, 1 there are but three common 
fevers which last more than two weeks, viz., typhoid, tuberculosis, and 
sepsis. This woman has cough, cyanosis, rales in both lungs, and, 
since the nostrils move visibly, she probably has dyspnea. May it not 
be that she has miliary tuberculosis with tuberculous peritonitis, the 
latter showing itself in one of those acute paroxysms which are so often 
mistaken for appendicitis, cholecystitis, intestinal obstruction, and other 
abdominal emergencies ? But if this is so, why is the patient not more 
emaciated after five weeks of illness? Unless we can get evidence of 
tuberculosis either in the family history, in the sputa, or in some other 
part of the body, there is no way of verifying this hypothesis any further. 

As we read that the Widal reaction was positive, it seems at first 
unnecessary to discuss the diagnosis further. There is nothing in the 
case to exclude typhoid, since lung signs like those here described may 
represent simply the ordinary bronchitis of typhoid. But as she has 
previously passed through an attack of typhoid fever, it may be that 
her Widal reaction is one of the residual results of that illness. We know 
that the Widal reaction may persist for thirty years or more after an 
attack of typhoid. The splenic enlargement is quite consistent either 
with typhoid or with tuberculosis. As there seems no good evidence of a 
generalized septic infection, and as the leukocyte count is at the outset so 
low, there seems no good reason to consider any disease other than typhoid 
and tuberculosis. The rarer causes of prolonged pyrexia (meningitis, 
rheumatism, syphilis, leukemia, malignant disease) do not deserve 
serious consideration. 

But there seem to be two acts to this drama, and the second — 
which began January 4th — throws considerable light upon the first, for 
the new pain gives every evidence of being due to cholecystitis, and 
cholecystitis is a common complication of typhoid, not of tuberculosis. 

Outcome. — Operation was done on the sixth and showed an injected, 
distended gall-bladder filled with pus, with a spot of gangrene on the wall 
and several stones within. 

The disease showed thereafter the ordinary course of typhoid. 
.ill's bacilli were recovered from the gal] bladder. 

Diagnosis. — Cholecystitis complicating typhoid. 

C« Cabot, The Three Long-continued Feven of New England, Boston Med 

ir^. J'»ur., August 29, 1907. 



240 




DIFFERENTIAL DIAGNOSIS 



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CHAPTER VII 

PAIN IN THE LEFT HYPOCHONDRIUM ^ 

The left hypochondrium is not a common place for puzzling pains. 
I have known very few diagnostic problems which centered there. 
Many discomforts arising from the stomach are felt in the left hypo- 
chondrium, but, as a rule, their origin and nature are tolerably clear. 

i. Flatulence, the commonest of all causes of pain in the lower left 
axilla, is also responsible for many complaints below the left ribs. The 
relief by escape of gas distinguishes many such pains, but we must 
remember that in many cases the flatulence itself requires explanation. 
Gas-formation may be the result, and its discharge the relief, of pain 
due to: 

(a) Angina pectoris. 

(b) Peptic ulcer and hyperchlorhydria. 

(c) Chronic appendicitis. 

(d) Gall-stones (rarely). 

Even toothache may cause recurrent flatulence and be temporarily 
relieved each time the gas (air ?) is discharged. 

2. Surgical disease of the kidney (stone, tuberculosis, neoplasm, 
local infection, hydronephrosis) occasionally causes pains in the left 
hypochondrium. More often, however, the pain is in the loin, in the 
lumbar region, or along the course of the ureter. The presence of a 
tumor and of urinary disturbances usually makes it clear that the kidney 
is the source of the pain. 

3. Adhesions about a spleen enlarged by leukemia, splenic anemia, 
malaria, syphilis, or polycythemia often produce pain in the left hypo- 
chondrium and above that point, but the obvious enlargement of the 
organ puts us on the right track unless we neglect physical examination 
altogether. 

4. Cancer of the splenic flexure of the colon rarely gives pain over 
d site. Usually such pains are in the umbilical region or diffused 

the whole belly. 
Some of the other diseases mentioned in Table # V may cause pain 
in the left hypochondrium as well as in the right (V. g. t pneumonia and 

pleui 1 [ally in children), but no separate discussion of them is 

W 21 1 



242 DIFFERENTIAL DIAGNOSIS 

On the whole, then, it appears to me that most pains in the left 
hypochondrium have either an obvious origin from one of the easily 
recognized sources mentioned above under i, 2, 3, and 4, or are to be 
explained by reasoning identical with that already applied to the 
right hypochondrium. Some of the possible occasions for doubt are 
exemplified in the following cases: 

Case 115 

A white-lead worker of twenty-one entered the hospital July 16, 
1906, with negative family history, past history, and habits, except that 
he had syphilis four years ago. Five years ago he passed some bloody 
urine, with clots, and at times nearly pure blood; this lasted for about ten 
days. He was well after that until two years ago, when he began to have 
dull, dragging pain under the left ribs, fairly constant day and night for 
two weeks, preventing work, but not preventing sleep. At this time 
he passed some " white stuff" looking like pus in his urine, mostly at 
the end of micturition. After two weeks he was well enough to be about 
and work, but he still notices the white stuff and occasional little strings 
in his urine. At times the urine is entirely clear, but for the past five 
months he says it has been clear for only five consecutive days. There 
has been no blood since four or five years ago. At times the urine smells 
very badly. Eight months ago and a year ago he had similar attacks of 
pain, relieved, as formerly, by the passage of pus. 

The present attack came on five months ago; he began to have dragging 
pain under the left ribs, severe enough to prevent work, but not sleep. 
At times it doubles him up. At the beginning of this period he thinks 
he had high fever. He now passes urine every hour. He has lost nearly 
20 pounds. 

Physical examination of the chest is not remarkable. In the left 
hypochondrium is an irregular mass, palpable bimanually, hard, and 
slightly tender. Its position is fixed. 

White cells, 11,700; the temperature ranges most of the time about 
99.5 ° F. There is no elevation of pulse or respiration. 

The urine shows pus, at times in large amounts, at times in very 
small amounts. It is not otherwise remarkable. Five milligrams of 
tuberculin were injected subcutaneously and caused fever, constitutional 
symptoms, and increased pain in the tumor. 

Discussion. — If we fixed our attention chiefly upon the history of this 
case, our first impression as to diagnosis would naturally be lead-poison- 
ing. Any abdominal pain in a lead-worker may be lead colic. We know 
also that lead affects the kidney. On the other hand, the physical ex- 



PAIN IN THE LEFT HYPOCHONDRIUM 243 

amination includes data not thus to be explained, and assures us that 
lead cannot play more than a subordinate part in the case. The mass, 
palpable bimanually, and the pus in the urine have nothing to do with 
lead. 

Abdominal pain in patients who give a history of syphilis should 
lead us to consider tabes with gastric crises. As we look over the case 
with this idea in mind, we note that there is no record concerning the 
pupillary reactions, the knee-jerks, or the ankle-jerks. We know that 
tabes often leads to bladder troubles, and sometimes to a retention of 
urine. In this way a cystitis and pyuria might have been produced, 
and thence, by ascending infection, a pyelonephritis. In this way all the 
facts might be accounted for. Actually, however, the pupillary and 
other reactions were normal, and there was nothing to support the 
hypothesis of tabes. 

Local renal disease giving rise to pyuria and tumor, with slight leuko- 
cytosis and fever, turns out most often to be due to renal tuberculosis. 
The positive reaction to tuberculin is not especially significant in an 
adult, since many adults react to tuberculin whether they are sick or well. 
More significant, however, is the increase of pain and sensitiveness over 
the tumor immediately following the injection. There seems to be no 
way of obtaining further insight into the nature of the trouble here pres- 
ent until we have further information in regard to the following points : 
(a) Can tubercle bacilli be demonstrated in the sediment of the centrifu- 
galized urine? (b) If not, what is the result of injecting this sediment 
into a rabbit or a guinea-pig? (c) What does x-ray show in the region 
of the kidney? Even without these data, however, renal tuberculosis 
seems the most probable diagnosis. 

Outcome. — On July 21st the kidney was opened and a considerable 
amount of pus evacuated from a trabeculated cavity in which were frag- 
ments of stone. There was no positive evidence of tuberculosis. 

Diagnosis. — Pyonephrosis with stone. 

Case 116 

A carpenter of thirty-seven, whose mother died of consumption, had 
an attack of "brain fever" eighteen years ago, and was in bed ten days. 
Ten ; he fell while carrying some heavy lumber and broke four 

rib-. He was laid up for twelve weeks, and his left side "has never been 
strong since." He has had bleeding piles lor seven years. His habits 
ood. 

ago he began to have needle like pains under the left costal 
:: about every fifteen minutes, usually not severe. Oo- 



244 DIFFERENTIAL DIAGNOSIS 

casionally the pains have been decidedly severe, radiating to the region 
of the heart and into the back. During these attacks he usually sweats, 
and at times, but not during the attacks of pain, his heart seems to 
pound. He has worked irregularly, and although at times he felt faint, 
he has never actually fainted. 

Twelve days ago he awoke in the night with great difficulty in breath- 
ing, severe knife-like pain about the heart, radiating to the left arm, cold 
sweat upon the forehead, and great weakness. The attack lasted five 
minutes. After that he staid in bed for a week with slight, needle-like 
pains as before, and an annoying general soreness about the heart, in the 
left arm and in the back. Four days ago he awoke with a severe grasp- 
ing pain in the region of the left nipple, extending through to the back, 
but not increased by deep breathing. He staid in bed for the next three 
days. To-day he got up and felt much better, but still feels heaviness 
and soreness in the left side. 

On physical examination the heart's apex is seen and felt in the fourth 
interspace, four inches to the left of midsternum. There is no enlarge- 
ment at the right. The sounds are regular and of good quality. A soft 
systolic murmur is heard at the apex, transmitted a short distance into 
the axilla. The artery wall is somewhat thickened above the elbow, but 
not beaded. 

Blood-pressure, 150 mm. of mercury at entrance; a week later, 
130. Blood and urine normal. 

In the left lower back, below and around the lower angle of the 
scapula, over an area the size of the palm, breath- and voice-sounds are 
diminished and fremitus is lessened. An area about two inches in diam- 
eter in the left midaxillary line, over the sixth and seventh ribs, is tender 
on pressure. There are scattered areas of tenderness over the ribs below 
this point. 

Discussion. — Flatulence is the commonest cause of pain like that 
here described, but the pain of flatulence is rarely so severe, and since 
there are no gastric symptoms to speak of, we cannot account for the 
patient's complaints in this way. 

The signs in the back of the left chest are consistent with a chronic 
pleural thickening, such as might result from tuberculosis, and the 
family history of that disease strengthens this possibility. But although 
it is quite possible that the patient has had tuberculous pleurisy, we can- 
not account for the paroxysmal painful attacks in this way, especially 
as they seem to be independent of respiration. 

The callouses due to broken ribs sometimes include nerve termina- 
tions and produce pain similar to that in the stump of an amputated 



PAIN IN THE LEFT HYPOCHONDRIA If 245 

limb. Presumably, we should interpret in some such way the patient's 
statement that his left side "has never been strong'' since he broke his 
ribs twelve years ago. But it seems very unlikely that the recent parox- 
ysmal attacks are due to his broken ribs. How large a part his old 
pleurisy may have played in his consciousness of weakness in the left 
side and in the heaviness and soreness which he still complains of it is 
difficult to say. The tenderness still complained of certainly cannot be 
due to pleurisy. 

Functional angina pectoris is the natural explanation for severe 
precordial pain extending to the left arm in a patient whose age and rela- 
tively low blood-pressure do not suggest organic disease of the cardio- 
vascular apparatus. This idea is favored by the long duration of his 
sufferings and by the fact that there is no demonstrable relation to 
exertion. 

In connection with paroxysmal attacks of this character, and more 
especially with precordial and left axillary pain of moderate severity 
and long duration, the physician must never forget the mental aspect 
of the case. Pain supposed by the patient to be in the region of the heart 
is always made up of two elements — (a) The pain itself; and (/;) what he 
thinks of it. The latter element is all the more important when it is largely 
unconscious. Dr. H. F. Vickery taught me years ago that, in dealing 
with patients who complain of pain in the precordial or left axillary 
region it is always well, after excluding organic disease by physical 
examination, to ask the following question: 

" Suppose you had that same pain in your shin, would you have come 
here to see me to-day?" 

This clever little psychologic device of Dr. Vickery's enables the 
patient to separate the pain itself from what he thinks of it, and to 
decide whether or not his fear of heart disease and its consequences 
has added to his sufferings. To think of the pain in his shin is to think 
of it freed from the additions and vague dreads sure to be associated with 
pain "around the heart." The very vagueness of these fears magnifies 
their organic effects, their tendency to aggravate pain. It is really as- 
tounding how rapidly such a pain will abate when the patient under- 
stands that his he-art is entirely sound. 

Outcome. — On further questioning it appeared that the patient 
smokes and chews tobacco constantly while at work. After ten days in 
the hospital, during most of which time the patient felt perfectly well, 

id that he wanted to go gunning; accordingly he was advised to 
stop the use of tobai co and discharj 

Diagnosis. -Functional angina pectoris. 



246 DIFFERENTIAL DIAGNOSIS 



Case 117 



A laundress of forty-five, with negative family history and past history, 
entered the hospital March 2, 1904. She passed the menopause six 
years ago. She has been markedly alcoholic for years. One month ago 
she began to have pain in the left hypochondrmm, relieved by painting 
with tincture of iodin. Three weeks ago she had a similar attack, re- 
lieved in the same way. Nine days ago she had some pain in the lower 
abdomen, relieved by a vaginal suppository. Since then she has been 
in bed for about half the time, owing to nausea and pain in the left hypo- 
chondrium. She says she has vomited blood, but her daughter has seen 
only greenish and dark-brown material. For a week the urine has been 
reddish. The patient has been pale for about five months. 

At entrance the patient was apparently in a uremic condition. The 
chest showed nothing abnormal. All the superficial lymph-glands 
were considerably enlarged. Only a few ounces of urine could be-' 
drawn from the bladder, and this nearly clear blood, some pus, no 
casts. Blood-pressure, 215. The patient was semicomatose, with 
coarse tremor of the hands. She died on the fourth of March. 

Discussion. — Peptic ulcer is naturally our first thought, but on 
further study of the case there seems to be little to support it. The 
condition of the abdomen and the high blood-pressure cannot possibly 
be thus explained. 

Cirrhosis of the liver, with associated splenic enlargement, might 
explain the abdominal symptoms. The vomiting of blood would then 
be the result of passive congestion of the stomach. The alcoholic his- 
tory makes this explanation plausible, but on careful palpation we do 
not get the impression that the abdominal masses shown in the diagram 
represent enlargement of the liver and spleen. There is no sharp edge 
on either side, and the respiratory mobility is slight. 

The general enlargement of the superficial lymph-glands might be 
due to syphilis. Enlargement of the spleen and liver is also frequently 
the result of this disease, and the pain of which the patient complains 
might be due to local peritonitis (perihepatitis and perisplenitis). The 
gastric hemorrhage might be explained under this hypothesis as a result 
of splenic fibrosis, the circulatory mechanism being the same as in 
splenic anemia. Against this, however, may be urged the same con- 
siderations which incline us to rule out cirrhosis: the abdominal masses 
do not suggest spleen and liver. 

By the same reasoning and by the negative results of blood examina- 




Fig. 38a. — Abdominal findings in Case 1 17. 






; 



PAIN IX THE LEFT HYPOCHONDRIUM 247 

tion we may exclude leukemia, although this disease would account for 
the glandular enlargement, and (through a cerebral hemorrhage) might 
explain the high blood-pressure and the semicomatose condition. 

Tuberculous peritonitis as part of a general tuberculosis might produce 
nearly all the symptoms of the case. This disease produces masses more 
or less vaguely felt in the abdomen, is often associated with abdominal 
pain, and, if we suppose an accompanying tuberculous meningitis with 
internal hydrocephalus, would explain the high blood-pressure and the 
psychic state. We should expect, however, some cranial nerve paralysis, 
some fever, and some signs in the lungs, even if only those of diffuse 
bronchitis; also some indication of a focus whence the disease, previously 
local, may have spread. Free fluid would probably be demonstrable 
in the abdomen. 

It is not definitely stated in the text that the abdominal masses 
were palpable bimanually, or that a connection with the kidney was thus 
suggested. Whenever we have reason to believe that some renal lesion 
exists, and whenever this lesion — although apparently of a gross, "sur- 
gical" nature — is associated with high blood-pressure, we should re- 
member the possibility of cystic kidney. It is rare to find any other non- 
nephritic lesion of the kidney associated with hypertension. Cystic 
kidney is generally a bilateral, congenital condition. Why, then, should 
these symptoms have appeared only within a month? Why should the 
disease have remained so strikingly latent? In answer, I can only say 
that this is the usual course of the disease, which encroaches upon the 
renal substance so slowly and so gradually that the system becomes 
accustomed to it, as to any other form of chronic interstitial nephritis, 
which is practically equivalent to the condition here described. Just 
what determines the final breakdown we usually cannot discover. 

Outcome. — Autopsy showed congenital cystic kidneys; there was 
almost no kidney substance remaining. There was hemorrhage into 
several of the cysts and pus in the pelvis of the left kidney. 

Diagnosis. Congenital cystic kidneys. 

Case 118 

A housewife of thirty-nine lost one sister of phthisis thirteen years ago. 
Family history otherwise good. In her seventeenth and in her twenty- 
fifth year she was in poor condition and was told that she Had anemia. 

1 she had her first attack of fever, with pain in the left lower 

abdomen. Since then she lias had more or less pelvic trouble, especially 

after standing or after working hard. About Christmas-time, 1906, she 
had frequent attacks of pain in the left upper abdomen; the pain doubled 



248 DIFFERENTIAL DIAGNOSIS 

her up, and was ascribed to gas in the stomach. During the winter 
the pain grew less, but the abdomen seemed to be enlarged. In March, 
1907, she noticed in the left upper abdomen a visible prominence, which 
has steadily increased up to the present time. By May she had to let 
out her clothes three inches, and thought she could feel a lump in the left 
side. 

Now (June, 1907) there is a dragging pain after standing, and a feeling 
of pressure when she lies on her left side. Since early spring she has had 
frequent attacks of palpitation, associated with pulsation in the neck, 
roaring in the ears, and slight dyspnea. Once during the summer she 
saw red spots in front of her eyes, but she has noticed no bleeding from 
any point. Her gums have several times been swollen. Three weeks 
ago, while urinating, she heard a sound in the chamber-pot, and looking 
in saw that the urine was very red and contained several hard, dark- 
brown masses about the size of a large pin's head. She felt no pain and 
noticed no stoppage of water. 

When examined at the hospital, her urine showed nothing worthy of 
note. 

Physical examination was negative except as regards the left hypo- 
chondriac region, where she felt an enlargement (as figured in the dia- 
gram, Fig. 39). The mass is only slightly tender, and moves freely with 
respiration; it is very firm. 

Discussion. — When a patient tells us that his stomach is so sore 
that he can't bear the weight of his clothes on it and that it is " all puffed 
up," examination generally shows nothing in particular, no actual disten- 
tion or prominence. Such symptoms usually occur in the neurotic, and 
represent the referred pain described so admirably by Henry Head. 
In the present case, however, physical examination shows that the patient 
is perfectly correct in supposing that the abdomen has enlarged. In- 
deed, the results of abdominal palpation make it unnecessary to consider 
any organs except the spleen and the kidney. 

The present tumor seems to be spleen rather than kidney, for the 
following reasons: 

(a) It has a sharp, hard edge, superficial and easily felt. Tumors 
of the kidney usually have no distinct edge, but shelve off into the depths 
of the abdomen. They are rarely as hard and superficial as those con- 
nected with the spleen. 

(b) In the present case the tumor descends at least an inch with full 
inspiration. Kidney tumors sometimes move half an inch, often not 
at all. 




Ii<^. 39. —Percussion outlines in a case of left-sided abdominal pain. 



PAIN IX THE LEFT HYPOCHONDRIUM 249 

(c) One cannot grasp this tumor bimanual ly, while bimanual pal- 
pability is especially common in renal tumors. 

(d) We are not told whether or not the air-distended colon overlies 
the tumor, but in view of its superficiality this seems very unlikely. 
Tumors overlain by the air-distended colon usually originate in the 
kidney or retroperitoneal glands. 

All the signs, therefore, in this case lead us to believe that the tumor 
is due to the spleen. Assuming, then, that this is the case, we have to 
consider the following possibilities: 

(a) Leukemia (proved or disproved by blood examination). 

(b) Malaria (proved or disproved by blood examination). 

The spleen may remain enlarged long after the malaria has died 
out, a fact very frequently illustrated in Armenian patients. In such 
cases, however, the patient presents no symptoms. 

(c) Syphilis (anemia, hepatic enlargement, and ascites often accom- 
pany the splenic enlargement); the history, the evidence of syphilis 
elsewhere, the result of treatment and of Wassermann's test, must 
decide. 

(d) Splenic anemia (diagnosis based upon the presence of a chronic 
anemia, secondary in type, often associated with gastric hemorrhages. 
All other causes for splenic enlargement must be excluded). 

(e) Cirrhosis of the liver and Banti y s disease. In cirrhosis we have 
a hepatogenous splenic enlargement; in Banti's disease, a splenogenous 
hepatic cirrhosis. The end-result is the same. Without evidence of 
cirrhosis, which is absent here, neither diagnosis can be made. 

(/) Splenic enlargement of unknown cause is a rare but well-recog- 
nized clinical entity. It produces no symptoms other than those de- 
pendent upon the weight and dragging of the enlarged organ. The 
diagnosis rests, of course, upon the exclusion of all known causes, 
such as have been listed above. Abscess, neoplasm, and echinococcus 
of the spleen are so rare that, for practical purposes, they ma}* be dis- 
regarded. The splenic enlargements accompanying acute infectious 
se never reach any degree comparable to that shown in the accom- 
panying diagram (Fig. 39). 

The next step in differential diagnosis evidently depends upon Mood 
examination. 

Blood examination shoved 277,000 white cells; 4,800,000 red cells; 
r rent, hemoglobin. Amon f ^ the white cells were 35 per cent, of 
^,4 per cent, of eosinophilesj 2 per cent, of mast cells; 52 per 
cent, of polynuclear cells. 

Diagnosis.- M; . bid leukemia. 



250 



DIFFERENTIAL DIAGNOSIS 



i 



Case 119 

A girl of six years, whose mother died of quick consumption, entered 
the hospital September 2, 1907. She drinks three cups of tea a day 
and eats considerable candy. She was recently operated on for con- 
genital cataract at the Eye and Ear Infirmary. For nine days she 
has been suffering from weakness, with tenderness and pain in the 
left upper quadrant of the abdomen. September 1st the white cells were 
19,000. The temperature was 103 ° F. The Widal reaction was nega- 
tive. There were no parasites in the blood. The urine showed a 
moderate amount of pus, but nothing else remarkable. 



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Fig. 40. — Chart of case 119. 



Examined on September 2d, the child is found to have moderate 
photophobia and seems apathetic. 

Examination of the abdomen is negative except that in the left 
upper quadrant there are considerable tenderness and slight spasm 
extending through the left flank into the back. There is also dulness 
from the seventh rib (anterior axillary line) to the costal margin. The 
patient is tender in the costovertebral angle. Culture from the urine 
shows a strain of colon bacillus, and a heavy pus sediment which lasted 
throughout her stay in the hospital. X-ray of both kidneys was normal. 
The temperature was as shown in the accompanying chart (Fig. 40). 



PAIN IN THE LEFT HYPOCHONDRIUM 251 

Discussion. — Surgical disease of the kidney is rare at this age. 
Renal tuberculosis and renal stone, which might account for such 
pain, are especially rare in small children. 

The dulness in the axilla, the pain, fever, and tenderness, might 
be accounted for by pleurisy. The text does not state whether or not 
these signs were supported by auscultatory evidences of disease. We 
should seek for diminution in the respiratory murmur, with decreased 
transmission of voice-sounds and of tactile fremitus. Friction-sounds 
might also be heard. As a matter of fact, however, neither of these 
confirmatory signs was present, nor was there any evidence of pneu- 
monia. I mention pneumonia and pleurisy especially because in children 
they are frequently ushered in by abdominal pain without any reference 
to the chest. 

The most notable feature in the physical examination is the presence 
of pus in the urine. Not many years ago this might have been passed 
over with very little attention, but since so much has been said and 
written of acute infection of the kidney, either hematogenous or ascend- 
ing, the urinary sediments are more carefully scrutinized. We are 
especially on the alert in young girls who, from babyhood up, are par- 
ticularly apt to acquire renal infection, presumably of the ascending type. 
The presence of the colon bacillus in pure culture in urine obtained 
under aseptic precautions, such as were observed in this case, lends 
support to the hypothesis of renal infection. In view of the negative 
results of #-ray, renal infection may be accepted as a working diagnosis. 
(For a discussion of clinical types of renal infection see Lumbar Pain, 
p. 99.) 

Outcome. — By the thirteenth of October the patient was well. 
The treatment consisted of counterirritants, laxatives, urotropin, 3 
grains, three times a day, and abundant water. 

Diagnosis. — Renal infection. 

Case 120 

A wool-spinner of forty entered the hospital March 3, 1908. He had 
been in the hospital four years before for " gastric indigestion." One 
sister died of cancer of the stomach at thirty-five. He takes four to six 
cups of tea a day. His habits are otherwise good. 

Since the fall of 1900 he has had intermittent pain in the left hypo- 
chondrium, worse on deep breathing, associated with belching, con- 
siderable nausea and vomiting, loss of appetite, and constipation. The 
vomitus consisted at first of sour liquid, later of yellow or greenish, bitter 
liquid containing no pus, blood, or mucus. Taking food sometimes 



252 



DIFFERENTIAL DIAGNOSIS 



makes the pain better, sometimes worse. He has often taken morphin 
to relieve the pain. For the past two weeks he has had the pain almost 
constantly. He has done no work. His best weight is 125 pounds. 
Now he weighs 117. 

The patient is pale and sallow, with pigmentation about the eyes. 
His pupils are small, equal, and react very slowly, either to light or 
distance. The tonsils are somewhat enlarged. The chest shows 
nothing abnormal, nor does the abdomen. The knee-jerks are very 
lively. Water-distention of the stomach with a tube showed that the 
organ held 28 ounces. On inflation, the lower border reached about 
one inch below the navel. After a test-meal free hydrochloric acid was 
0.32 per cent. Lactic-acid and the guaiac tests were negative. No 
fasting contents were obtained. 

Discussion. — We have here a long period of suffering from chronic 
dyspepsia, which has led, as it so frequently does, to the taking of 
morphin. It is well to remember this fact, since abdominal pain that 
leads to a call for morphin is often associated in our minds with the 
diagnosis of gall-stones. 

Further analysis shows us that the motor power of the stomach 
is good and its outlet free. There has been no vomiting of food, but only 
of liquid which may be interpreted as gastric secretion. Tube exam- 
ination shows no stasis. Since most gastric cancer produces pyloric 
stenosis and stasis, the absence of stasis in this case, especially in view of 
the long duration of the symptoms (1900-1908), makes cancer unlikely. 

Of leukemia, pleurisy, and the other extragastric causes for left 
hypochondriac pain, physical examination shows no evidence. Cancer 
of the splenic flexure might produce most of the symptoms here present, 
but there is no palpable tumor nor visible peristalsis, no diarrhea, and no 
blood in the feces. The constipation here described might be due to 
many causes. 

The high percentage of hydrochloric acid in the gastric contents is in 
itself a partial diagnosis, and might account for many of the symptoms. 
Our chief remaining problem is to determine whether anything more 
serious than hyperchlorhydria is present. Many — probably most — cases 
in which hyperchlorhydria is associated with symptoms so long continued 
and so severe turn out sooner or later to be peptic ulcer. No further 
exactness of diagnosis is possible without operation. The absence of 
the reaction to guaiac, both in the stomach-contents and in the feces, by 
no means excludes ulcer. 

What treatment should be advised here? The proper rule in such 
cases seems to me to be this: give a fair trial to treatment by hygiene, 






PAIN IX THE LEFT HYPOCHONDRIUM 



253 



diet, and drugs; if these fail to make the patient reasonably com- 
fortable., advise operation. It does not seem evident, from the data here 
presented, that any persistent attempt has been made to control the 
symptoms by non-operative measures. Such measures should, there- 
fore, be tried first. I have had excellent success with a modification of 
Lenhartz's diet, suggested by Dr. H. F. Hewes, which consists essentially 
of the following regimen: 

For the first two or three days: For the next two or three weeks: For tlie final two months: 

2 ounces of milk. 6-8 ounces of milk. Milk and crackers. 

1 powdered soda-cracker. 4 powdered crackers. Indian-meal mush with cream 

1 cunce of sugar. 1-2 ounces of sugar. or salt. 

□ every two hours Eight such feedings in Potato puree; jelly. 
while the patient is awake. twenty-four hours. Milk and whites of two eggs. 

Soft custard. 
Chocolate. 
Pea puree. 

Eight feedings in twenty-four 
hours. 

If the patient is uncomfortable despite this diet, he should take 
cooking-soda in doses sufficient to relieve him. What this dose is can be 
ascertained only by experiment. It may be anywhere between 10 grains 
and 2 drams. 

Outcome. — On a subsequent examination free hydrochloric acid 
after a test-meal was 0.11 per cent. The patient complained of "cold 
sweats" at night, but under careful diet, small doses of calomel and 
seidlitz, olive oil, two teaspoonfuls after meals, and an occasional lavage, 
he seemed practically well by the eleventh of March. Rest and freedom 
from worn- seemed to have much to do with his recovery, which by the 
nineteenth was complete. 

Diagnosis.— Hyperchlorhydria. 

Case 121 

A teamster of forty-four entered the hospital April 4, 1908. He 
has always been well until four years ago, when he was working on the 
great Clinton dam; a blow in the left side by a heavy pile laid him up for 
six weeks, during which he suffered from pain in the Left side and had 
Moody urine. Since that time he has never been entirely free from pain 
in this region, and after any unusual exertion lie lias passed blood}' urine, 
fall lie had to give up work because of the severity of the pain. 
Three weeks ago he had a specially sharp pain in the left hyjnn hondrium 

the ribs, the pain traveling down the left leg, occasionally 

1 left testis, and up toward the heart. Since then he has had three 



2 54 DIFFERENTIAL DIAGNOSIS 

or four attacks, lasting from five to twenty-four hours, all of the same 
character. When the pain is severe he vomits, and is relieved to a certain 
extent thereby. There is tenderness under the ribs in the left hypochon- 
drium during and after his attacks. He has been in bed most of the last 
three weeks, but has passed no bloody urine. His weight, eighteen months 
ago, was 197 pounds; now it is 167. 

Physical examination shows nothing wrong in the chest. The arteries 
are easily palpable. The aortic second sound is louder than the pulmonic. 
Blood-pressure, 140. In the left lumbar region there is slight volun- 
tary spasm and tenderness, increased by inspiration. 

The temperature, pulse, respiration, and blood are normal. 

The urine amounts to 40 ounces in twenty-four hours; 1022 in 
specific gravity; it shows a trace of albumin and many fresh red blood- 
cells. No casts. 

Discussion. — Can we connect the symptoms with the injury sus- 
tained four years previously? The patient had hematuria immediately 
after this, and he has had it more or less ever since. Can we conceive 
any type of trauma which would produce an effect so lasting? I do 
not see that we can. The trauma, I think, must be regarded as having 
no important connection with his present disease. 

In the absence of all bladder symptoms, causes of hematuria arising 
there deserve no further consideration. The clinical picture is one of 
renal colic associated with hematuria and a loss of 30 pounds in weight. 
Malignant disease of the kidney would produce these three symptoms, 
but would hardly have lasted so long. Either it would have killed the 
patient or it would have produced a palpable tumor. The hemor- 
rhages from renal tumor are apt to be longer continued and of larger 
amount, leading to decided anemia. 

Tuberculosis of the kidney of anything like this duration would have 
produced tumor and pyuria. It may be easily excluded. 

Chronic nephritis, either of the glomerular or the interstitial type, 
may be complicated by sudden attacks of hemorrhage unassociated with 
any special increase in the other urinary manifestations of disease 
(casts, cells, deficient solids). Such hemorrhages may be painless, or 
may lead to colic, owing to the formation of clots and the difficulty of 
their expulsion into the bladder. The present case, however, shows no 
signs of nephritis. 

We have left the two commonest and most puzzling occasions for 
hematuria: (a) stone and (b) unknown cause. The latter is, I believe, 
one of the most frequent of all the types of hematuria. Between this 
and stone our chief means of distinction is the x-ray examination. 




Fig. 41. — Outlines of mass referred to on p. 255. Palpable bimanually. 



PAIN IX THE LEFT HYPOCHOXDRIUM 



255 



Outcome. — X-ray taken April 8th showed a small round shadow in 
the region of the left kidney. Cystoscopy helped to confirm the diag- 
nosis of stone. The stone was subsequently found at operation. 

Diagnosis. — Renal stone. 

Case 122 

A clerk of thirty-live entered the hospital October 21, 1907. He 
was operated on for appendicitis four years ago. He had left-sided 
pleurisy at the same time. He says he has always been pale. Eight 
weeks ago he began to have a sore, uneasy feeling, first in the left lower 
quadrant, later in the left hypoclwndrium, left hip, and over the left 
kidney in the back. He has also had numbness in the leg, extending 
from groin to knee. Three and a half weeks ago he first noticed a 
lump in the left upper quadrant, and began at the same time to have a 
very obstinate constipation — the bowels moving scantily by enema 
only. Xo blood seen in the stools. 

Examination showed pallor of the mucous membranes and negative 
chest, while in the left upper quadrant there were marked resistance 
and tenderness. There is also considerable tenderness over the anterior 
muscles of the left thigh. Four days later palpation of the left flank 
had become easier, and a mass filling the whole flank from back to 
front, immobile and slightly tender, was easily felt. Blood-pressure 
normal. The inflated colon lay in front of the mass. Urine: 40 ounces 
in twenty-four hours; normal color; 1020; no albumin; sediment 
negative. (See Fig. 41.) Physical examination otherwise negative. 

Discussion. — Is it possible that this patient's pleurisy of four years 
•go is in any way connected with his present symptoms? It is a familiar 
fact that after any pleurisy most patients have a certain amount of 
pain in one or another part of the affected side of the chest, a pain that 
lasts on, oftentimes, for months and even years. But in such cases we 
t to find some residual signs of the old pleurisy, and there seems 
to be nothing of the kind here. It is obvious, moreover, that pleurisy 
could not explain more than a small fraction of the facts in this case. 

Leukemia would explain the lump and the: pallor. Even in advance 
of Mood examination, however, leukemia is practically excluded by 
the fact that the colon passes in front of the tumor. The blood examina 
tion was also negative. 

Iicer of the splenic flexure of the colon would produce a mass in 

,l iis situation, and might account for all the pains here described. 

cpect, however, if such a cancer existed, to get sonir of 

irdinary evidences of intestinal obstruction, Mich as visible peri 



256 DIFFERENTIAL DIAGNOSIS 

stalsis, intestinal noise, gross or occult blood in the stools, diarrhea, or 
constipation. None of these symptoms was present except the con- 
stipation, which may well have been due to other causes. 

The tumor is in the position usually occupied by growths arising 
from the kidney. Tuberculosis, cyst, and neoplasm may be considered. 
Against tuberculosis is the fact that we have no fever and no pyuria. 
The amount of pain and the extent of its radiations exceed what we 
usually find in renal tuberculosis. The latter remark applies also to 
renal cysts, which often attain a much larger size than the mass here 
present without producing any pain at all. Most chronic renal cysts 
also produce an elevation of blood-pressure, which did not exist here. 
New-growths of the kidney might explain all the symptoms that are 
here present, but in most cases would also cause hematuria. The 
nodular surface of the growth, if the observation be correct, would 
identify it almost certainly with a neoplasm. In some cases, how- 
ever, the irregularities of a cystic kidney or of a tuberculous kidney 
feel very much like the nodules of malignant disease. 

Outcome. — The patient was operated on March 25th, and hyper- 
nephroma found. 

Diagnosis. — Hypernephroma. 

Case 123 

A single woman, thirty- three years old, was first seen June 28, 
1 901. Family history, personal history, and habits excellent. Eight 
years ago she weighed 122 pounds; now, 104. 

For two years she has had almost daily attacks of severe general 
bellyache with rumblings; the pain is worse in the left hypochondrium, 
lasting one to twelve hours, doubling her up, making her cry aloud, 
and radiating to the left shoulder. The pain has no clear relation to 
food. When the pain occurs, she usually vomits, and is promptly re- 
lieved thereby, but in the last seven months she has vomited only twice. 
Vomitus consists, as a rule, of food eaten recently, but on several occa- 
sions it has contained food eaten two days before and exceeding the 
amount of the last meal. 

She has distress and acid eructations one-half to one hour after 
meals. Diarrhea often comes with the attacks of pain (3 or 4 move- 
ments). Mucus, but no blood, has been seen in the feces. 

She has worked except during paroxysms of pain. 

Examination. — Well nourished. Visible peristalsis below the navel, 
with slight general fulness of the abdomen. Much gurgling. No 



PAIN IN THE LEFT HYPOCHONDRIUM 257 

tenderness. Leukocytes, 8800; hemoglobin, 95 per cent. Borborygrm 
can be heard all over the house. 

Stomach and its contents negative. Temperature (three weeks) 
normal. 

Discussion. — The complaint of long-standing gastric pain and 
the evidences of gastric stasis make it reasonable to consider briefly 
the possibility of hyperchlorhydria or of a constricting ulcer near the 
pylorus. Most of the patient's complaints might be thus accounted 
for. Two facts, however, militate against this diagnosis : (a) Peristalsis 
is visible below the navel. In a well-nourished patient this has con- 
siderable diagnostic value, and points to the intestines rather than to 
the stomach as the source of trouble, (b) Very loud intestinal noise 
is a feature of the case. This, like the peristalsis, directs our attention 
away from the stomach. 

The record of the physical examination is printed here as it was 
given me by the attending physician. In it we lack the data necessary 
to exclude lead-poisoning and tabes, either of which might account for 
part, if not for the whole, of the symptoms. My own examination dis- 
closed no lead dotting of the gums, no basophilic stippling of the red 
cells, no abnormalities of the ocular or tendon reflexes. The age and 
symptoms are consistent with gastric neurosis were it not that visible 
peristalsis is revealed by examination. 

With the exclusion of the possibilities mentioned above, chronic 
intestinal obstruction is left as the most plausible diagnosis. But what 
is its cause? In any patient who has had no known cause for the forma- 
tion of adhesions within the peritoneal cavity (appendicitis, pyosalpinx, 
or gall-bladder disease, with or without operation), cancer is the com- 
monest cause for chronic intestinal obstruction. The age of this patient 
does not enable us to exclude this disease. More important evidence 
against cancer is the duration of the symptoms. Cancer of the gut 
often lasts two years or more, but in such cases it usually produces 
a palpable tumor. In the absence of any such tumor our best diagnosis 
is: chronic intestinal obstruction of unknown origin; the most significant 
symptoms being the visible peristalsis and the loud intestinal noise. 

Outcome.— Operation, July 17th, showed strictures 1 to 6 Inches 
in the small gut. The gut was thickened and, in the contracted 
portions of it, tubercles could be seen. 

Diagnosis. — Tuberculous enteritis. 

17 



CHAPTER VIII 

RIGHT ILIAC PAIN 

Case 124 

A girl, fifteen years old, was first seen July 21, 1898; six months 
ago she began to get run down. Pallor, dyspnea, anemia, and weak- 
ness brought her to the out-patient department, where, March 26th, the 
hemoglobin was found to be 55 per cent. Patient had moderate general 
abdominal pain throughout her illness, but did not complain loudly of 
it until June 21st, when it began to be localized chiefly in the right iliac 
region. It is more soreness than pain, she says. Jolting in a wagon 
or rising from a chair aggravates it. She limps in walking lately. 
Otherwise feels well. No fever (two weeks' observation). Bowels reg- 
ular. Last menstrual period ten days ago. 

Examination. — Negative save for a large hard "cake" filling most 
of the right iliac region nearly to Poupart's ligament. On the lower 
side of the mass is a tender prominence diagonally placed. Leukocytes, 
7400; hemoglobin, 95 per cent. Urine negative. Vaginal examination 
negative. 

Discussion. — The essential point in this case is the presence in 
the right iliac region of a large mass, associated with anemia and pre- 
ceded in its development by a considerable period of general constitu- 
tional symptoms, such as weakness and dyspnea. All this in a girl of 
fifteen can hardly be due to the cause which ordinarily produces such 
symptoms in the latter half of life — namely, malignant disease. 

For appendicitis or pyosalpinx the onset seems rather too gradual, 
the preceding constitutional symptoms too marked, the fever and 
leukocyte count too low. What was known as to the girl's circum- 
stances seemed to render gonorrheal infection very unlikely. 

Ovarian tumors, especially those of the dermoid type, may occur in 
girls of this age, but rarely produce so much constitutional disturb- 
ance, and are not apt to be described as a "cake," being, as a rule, 
elastic and globular. The catamenia have been regular, the last period 
occurring so recently that extrauterine pregnancy seems impossible. 

Many points in the case suggest pericecal tuberculosis. These 
points are especially the early general weakness and anemia, the slow 

258 



Causes of Right Iliac Pain 



1. APPENDICITIS 

2.PUS-TUBE) 
(AND PELVIC \ 
ADHESIONS) ) 

3. DYSMENORRHEA 

4. EXTRA-UTER-] 

! N E PREG- 
NANCY i 

5.0VARI AN1 
CYST WITH ! 
TWISTED 
PEDICLE J 

6. PSYCHONEU- 
ROSI S AND 
THE FEAR 
OF APPEN- 
DICITIS 



7. COLICA MUCOSA | 

I 



8. URETERAL i 
STONE / 



1169 

427 

31 

23 

21 

17 

5 
4 



Obstruction in the ileocecal region {neoplasm, tuberculosis, adhesions) 
occasionally produces right iliac pain. As a rule, however, the pain 
is not thus localized. 

Inguinal hernia produces usually an inguinal pain with radiations 
which may involve the iliac and other neighboring regions. 

Any of the causes of generalized abdominal pain (e.g., tuberculous 
peritonitis) may produce right iliac pain. Conversely, the local causes 
above mentioned may in exceptional cases lead to generalized pains. 

Many of the dragging " bearing down " inguinal pains of debilitated 
woiiii age So) extend now and then to hhi or the Other iliac 



: 






RIGHT ILIAC PAIN 26 1 

onset and moderate degree of abdominal soreness, the large size of the 
mass. Against this diagnosis is the absence of fever and of any con- 
siderable disturbance of the bowels. One expects constipation, with 
or without intervals of diarrhea. The diagnosis then lies between 
ovarian cyst and pericecal tuberculosis, -inclining rather toward the latter. 

Outcome. — Operation, August 4th, showed a tumor the size of a 
lemon, studded with tubercles — pericecal abscess with the tube also 
involved. 

Diagnosis. — Pericecal tuberculosis. 

The two following cases do not seem to me to admit of any accurate 
differential diagnosis previous to operation. They are introduced here 
to suggest the variety of clinical pictures which pericecal tuberculosis 
may present. 

Case 125 

A little girl of six was first seen September 19, 1905. She had 
whooping-cough January, 1905. Since then she has made frequent 
complaints of pain in the right iliac fossa, worse after meals, and has 
vomited almost every day. For five months she has had tenderness 
in the painful region. No other complaint. 

Appetite good; bowels regular; urine normal. 

Examination. — Poorly nourished. Chest negative. Belly nega- 
tive, save for slight tenderness in the region of the appendix. Leuko- 
cytes, 8000. No fever. 

Operation as for appendicitis. Tuberculosis was found in a loop 
of small gut about four inches long. This was excised and the diag- 
nosis confirmed by microscope. 

A year later (November 28, 1906) was in "splendid general condition. 
Appetite, bowels, and sleep satisfactory. Some thickening in cecal 
region." "Several abscesses have broken through," and in October 
she entered the Children's Hospital and was very sick for twelve days. 

Pain occasionally wakes her at night (spasmodic pain with rumb- 

. but she soon drops asleep. She sometimes vomits with pain — 

Once daily on an average. Wets bed once or twice a week. Is listless 

and disinclined to exertion. No dyspnea. Weight, 31 pounds. Slight 

tance in appendix region. No spasm; no tendernes 

Diagnosis.-- Pericecal tuberculosis. 

Case 126 

A young Assyrian was admitted March 10. 1000, for chronic appen- 
ral attacks of right iliac pain in the past year. Diarrhea 



262 DIFFERENTIAL DIAGNOSIS 

with one attack. No vomiting. Most of the attacks last a few hours 
only. Bowels regular. 

Examination. — Chest negative. Belly negative except for a large 
mass indefinitely outlined in the right iliac region, with slight tenderness 
and spasm. 

Mass was not affected by free catharsis. Comfortable. No fever. 
Pulse, 90. 

Operation March 21st: Some free fluid. A nodular mass in the ileo- 
cecal region. Similar smaller masses could be felt in the mesentery and 
along the cecum. Cecum adherent. 

April 14th discharged well. 

Microscopic examination of excised piece showed tuberculosis. 

Diagnosis. — Tuberculosis of the cecal region. 

Case 127 

Consulted October 23, 1902, by a married woman of thirty-one 
who has had left tube and ovary removed at Boston City Hospital in 
1897. For eighteen months she has been more or less constantly in 
pain, referred to the right lower quadrant. For the past six weeks it 
has been severe. No fever or chills. Last menses in July, and again 
three weeks before entrance, when she flowed for five days, using five 
napkins a day. Many clots came away, one the size of a hen's egg. 

The diagnosis of the attending physician is extrauterine pregnancy. 

Examination. — Tenderness over the uterus and in appendix region. 
Movable pelvic mass on the right, thought to be closely attached to the 
uterus, which does not seem enlarged. 

The patient ran a slightly elevated temperature with a normal pulse. 
Her general condition was excellent. Twelve days' observation. 

Discussion. — The essentials in this case are right iliac pain of 
eighteen months' duration and amenorrhea of three months. The 
latter fact strongly inclines us to believe that the genital tract is in- 
volved, and tends to exclude a simple appendicitis. Amenorrhea is 
consistent with any of the following possibilities: Normal pregnancy, 
extrauterine pregnancy, pyosalpinx, ovarian cyst, 1 fibroid tumor, peri- 
tubal tuberculosis. It is, however, less frequent in ovarian cysts and 
in pyosalpinx, and very much less frequent when fibroid tumors are 
present than in either form of pregnancy. The flow which is said 

1 1 shall make no attempt in this or in subsequent cases to distinguish between ovarian 
and parovarian cysts, nor between either of these and a cyst of the broad ligament or a 
hydrosalpinx. I do not believe that these can often be distinguished by physical ex- 
amination alone. 



RIGHT ILIAC PAIN 263 

to have occurred three weeks before entrance, came at a time not cor- 
responding to the menstrual period. In many ways it sounds like a 
miscarriage, but one must be on one's guard when patients give a 
history such as this, for not infrequently stories of pure fabrication are 
:ied to induce the physician to curet the uterus and thereby to 
bring about a miscarriage. 

Very possibly the diagnosis might have been made clearer had a 
uterine sound been introduced, but in view of the possibility of pregnancy 
this was obviously improper. On the whole, the diagnosis seems to me 
to be impossible, and the case is introduced merely as an example of 
the present limitations of our diagnostic skill. 

Outcome. — Operation for ovarian cyst revealed normal pregnant 
uterus (three months) strongly right latero-verted. Subsequently 
tried to miscarry at six months but failed, and child was born at 
term (Boston Lying-in Hospital). 

Diagnosis. — Normal pregnancy. 

Case 128 

A married woman of forty-two; has one child two years old, and 
suffered a miscarriage three years ago. 

For three months has had periodic attacks of pain in the right 
lower abdomen which make her feel "sick all over." These came at 
first every four weeks, now every two weeks. Vomiting, constipation, 
distention, relieved by enemata. Catamenia normal. 

Last attack began ten days ago, and pain has persisted since. It 
shoots into right hip and flank. When she reaches out for anything 
she has a sense of tension in the right lower belly. 

Examination. — Hard, smooth tumor in right iliac region, fairly 
tender, about size of a large orange. No fluctuation. Vaginal examina- 
tion cannot determine whether or not tumor is connected with uterus. 
Xo fever. Leukocytes normal. 

Discussion.— We rightly consider appendicitis in every patient 
who complains of right iliac pain, but in the presenl case this possibility 
may be promptly dismissed. An appendix abscess rarely if ever lasts 
so long or attains such a size as this without producing more con- 
stitutional and local disturbani 

Tubal absce>s would probably produce more tenderness, and rarely 
attains this size. The woman's age is not typical tor tubal disease, though 
this, in itself, is not a point of great importance. 

The tumor suggests especially uterine fibroid and ovarian CVSt 
Fibroids are more apt to be- situated in the median line and to be obvi- 



264 DIFFERENTIAL DIAGNOSIS 

ously connected with the uterus. They are rarely smooth. Unless they 
lead to profuse flowing, they usually cause no symptoms of any impor- 
tance until a considerably greater size has been reached. 

Except for its extreme hardness and the absence of mobility, the 
tumor is fairly typical of ovarian cyst. Cysts of this size rarely produce 
marked symptoms unless the pedicle becomes twisted, with resulting 
necrosis, hemorrhage, or local peritonitis. Any of these conditions may 
be here present. 

Outcome. — Operation showed a cyst the size of a child's head. 
Its pedicle was twisted. The patient was discharged in three weeks. 
A year later she was heard from and had remained entirely well sincf 
her operation. 

Diagnosis. — Ovarian cyst with twisted pedicle. 

Case 129 

An Italian laborer of twenty-four entered the hospital August 22, 
1908, complaining of right iliac pain which has been severe only for 
ten days, but had troubled him off and on since March. He has had 
no constipation, vomiting, jaundice, or headache. 

The pain is worse at night, is somewhat relieved by applications 
of iodin, and somewhat increased by the taking of food. 

Worked until four days ago. Family and previous history good. 

Examination. — Scars in the neck near the angle of the jaw. Tender- 
ness throughout the belly on deep pressure, most marked in the right 
iliac region. Physical examination, including the blood and urine, tem- 
perature, pulse, and respiration, showed nothing else that was abnormal. 

Discussion. — This case was operated upon as one of acute appendi- 
citis. Against this diagnosis, however, were urged the following con- 
siderations, to which, as I think, insufficient attention was paid. The 
patient's pain was never sharp and never well localized. The same was 
true of his tenderness. He never suffered from constipation, vomiting, 
or fever; his blood showed no leukocytosis. In view of these facts it 
seems to me that all the other possibilities should have been considered. 

His symptoms have been of long standing and have increased little 
in severity. The long history of the case, the scars in the neck, and the 
fact that the patient is a recently arrived Italian immigrant, make ab- 
dominal tuberculosis a genuine possibility. Many cases of abdominal 
tuberculosis produce no more symptoms than are here described, al- 
though the absence of fever is somewhat surprising. 

The pain has none of the radiations characteristic of stone in the 
ureter, and there has been nothing in the urine to suggest this disease. 



RIGHT ILIAC PAIN 265 

Gall-stone pain is sometimes referred to the right iliac region, but no 
diagnosis of gall-stone disease is possible upon the evidence here pre- 
sented. There seems no good reason to suspect any part of the gastro- 
intestinal tract. 

Young Italian laborers rarely suffer from fimctional neuroses. I have 
once known a case somewhat similar to this in which the patient turned 
out to be a malingerer, but he had obvious reasons for his lies, while this 
patient has none. On the whole, I think that, had tuberculosis been 
seriously considered by the surgeon who performed the operation, the 
diagnosis of appendicitis would never have been made. 

Outcome. — Operation revealed a normal appendix. Many glands 
of the size of marbles were felt in the mesentery and along the spinal 
column. Two of them seemed a little soft on one side. The patient 
made a rapid and permanent recovery. 

The outcome of this case seems to me to prove that the glands were 
tuberculous. The patient's recovery proves that they were not malig- 
nant, and there is nothing to make us suspect typhoid. What should 
have been the treatment had the diagnosis been known before operation? 
Clearly, I think, it should have been purely a hygienic and dietetic 
one, similar to that applied in pulmonary tuberculosis. 

Diagnosis. — Tabes mesenterica. 

Case 130 

A young married woman complains that since her second child was 
born, four months ago, she has had intermittent right iliac pain in spells 
of one to two weeks. It is worse on standing or exertion. 

Examination. — Slight enlargement of the thyroid. Flat, globular, 
smooth mass, the size of a grape-fruit, is felt in right iliac region. It 
can be moved to the other side of pelvis. Distinct fluctuation wave over 
it. Xo connection with uterus can be made out. 

Next day (September 15th), at 4 P. M., sudden right iliac agony with 
vomiting. It lasted until 12 P. M. Then she slept (no drug). Free lluid 
was demonstrated in the peritoneal cavity. 

September 16th, comfortable in day — similar attack in evening. 

September 17th: Operation: Ovarian cyst with twisted pedicle (free 
bloody fluid — as usual). 

Discussion. — This is a typical case, quite easy of diagnosis. The 
smooth, globular, painful mass in the right iliac region, the free mobility 
of the tumor, the sudden advent of agonizing pain, and the evidences 

of free fluid in the peritoneal cavity make Up the typical picture of ovarian 

i tli twisted pedicle. In many, perhaps most, cases, however, we 



266 DIFFERENTIAL DIAGNOSIS 

cannot be so sure either of the cyst or of the twist because we have had 
no opportunity to question and examine the patient previous to the advent 
of any acute symptoms. Very large, centrally placed cysts are recog- 
nizable in case they project sharply forward, leaving the flanks compara- 
tively free from bulging and still resonant on percussion. The diag- 
nosis is much aided if the patient has been able to notice that the tumor 
originated at one side of the abdomen and only assumed its central 
position at a later date. But the majority of patients remember nothing 
of the kind and pay no special attention to their condition until it gradu- 
ally dawns upon them that the enlargement cannot be due either to 
fat or to the so-called "high stomach." Under these conditions it may 
be difficult or impossible to distinguish the disease from tuberculous 
peritonitis. The other and commoner causes of ascites (cirrhosis, cardiac 
or renal disease, cancerous peritonitis) are more easily recognized. 

In another group of cases the cyst is smaller and bears no great re- 
semblance to an ascitic accumulation, but is of such a board-like 
hardness that we can scarcely imagine its contents to be fluid. A careful 
examination under ether and the introduction of a uterine sound will 
usually determine the point. 

As a rule, it is useless to attempt any distinction of the different 
varieties of ovarian tumor. Occasionally the smaller and more solid 
tumors (ovarian fibroid, cancer, or sarcoma) may be recognized by their 
consistency, and especially by their association with ascites, which is 
much commoner with solid than with cystic tumors. 

The occurrence of a twist in the pedicle of an ovarian tumor is often 
recognized without difficulty, provided we have seen and studied the case 
before the twist occurred. If we know that an ovarian tumor is present, 
the occurrence of any kind of acute abdominal symptom is strongly sug- 
gestive of a twist. But if we see the patient for the first time after the acute 
symptoms have appeared, it may be quite impossible to make out any- 
thing which enables us to distinguish the condition from perforative 
peritonitis or intestinal obstruction. The abdomen may be so tender and 
its muscles so spastic that nothing definite is distinguished on physical 
examination, while the pain, vomiting, constipation, and general pros- 
tration are quite equivocal. 

Diagnosis. — Ovarian cyst with twisted pedicle. 

Case 131 

A seventeen-year-old school-girl has had three attacks like the present 
one, the last eight months ago. Catamenia regular and normal. 



RIGHT ILIAC PAIN 267 

Yesterday general abdominal pain, with vomiting and diarrhea, 
brought her to her physician. 

Examination. — Temperature, 102 F.; pulse, 105; respiration, 25. 
Slight rigidity and considerable tenderness in right iliac region. Leuko- 
cytes, 14,000. Operation: Normal appendix. Considerable bloody 
fluid in pelvis. Ruptured ovarian cyst one inch in diameter, whence 
oozed gelatinous material. 

Discussion. — Much that was said in the discussion of the last case 
applies equally to this one. With no accurate knowledge of her condi- 
tion previous to the present attack, appendicitis was the most natural 
and reasonable diagnosis. Such mistakes cannot be avoided. It is on 
this account that T have not discussed ruptured ovarian cyst in detail 
among the possibilities to be considered in differential diagnosis, as I 
have intended to deal chiefly with the recognizable and verifiable possi- 
bilities. 

Diagnosis. — Ruptured ovarian cyst. 

Case 132 

A married woman of forty-seven was seen January 25, 1908. Eight 
months ago, on getting out of bed, she felt sudden sharp right iliac 
pain, which ceased in one hour on lying down. Many attacks since — ■ 
lately, three or more every week. 

Two months ago noticed a lump in right side of belly. Thought 
she was getting fatter there; lump seemed larger during the attacks of 
pain. Thinks she has lost weight in the rest of her body. 

Examination. — Thin, worn face. Belly prominent, especially to the 
right of the median line below the navel. Dull here, tympany elsewhere. 
A large, slightly compressible mass, extending from the pelvis to a hand's 
breadth above the navel. Not tender; freely movable. Vaginal ex- 
amination adds nothing. 

Operation revealed a multilocular ovarian cyst about 2 | cm. in diam- 
eter. There were no adhesions except a few about the appendix. 
Well in two weeks. 

Discussion.- This case is introduced to exemplify the occurrence 

of attacks of pain in connection with an ovarian cyst easily recognizable 
as such. These attacks, however, were demonstrably not due to a 

ting of the pedicle. Their cause is not explained. 
Diagnosis. ( )vari;m cyst. 



268 DIFFERENTIAL DIAGNOSIS 



Case 133 



A man of forty-eight has had for two days pain in right side of belly, 
extending to the back, tending to shoot upward, and increased by motion. 
Dull ache with exacerbations. No other symptoms. 

Temperature, ioo° F.; pulse, 62. Leukocytes, 12,000. 

Tenderness in right loin and along the ureter down to McBurney's 
point. No muscular spasm. Urine normal. 

The tenderest areas are: (a) Midway between the ribs and the ante- 
rior superior iliac spine; (b) over the right kidney. 

Discussion. — Although this case was diagnosed and operated upon 
as appendicitis, there are several points distinctly against that diagnosis. 
In the first place, it is important that the pain — and especially the tender- 
ness — centered rather in the loin and over the ureter than at McBurney's 
point. The absence of muscular spasm is also distinctly against appen- 
dicitis. Dull aching pain with exacerbations occurs in appendicular 
colic, but also in colic of other origin (intestinal, biliary, renal, uterine). 

So much in this case suggests kidney that, even though the urine is 
normal, cystoscopy and the introduction of a catheter into the ureters 
seems indicated. 

Outcome. — Operation showed in the ureter a stone the size of a 
large bean. Recovery was uneventful. 

Diagnosis. — Stone in the right ureter. 

Case 134 

A factory girl of twenty-four entered the hospital June 21, 1906. 
She had pleurisy eighteen months ago. One month ago, without known 
cause, her abdomen began to be sore and tender on pressure, especially 
in the lower portion and on the right side. There has been no actual 
pain, but she has been too weak to work, and has been part of the time in 
bed. The menses have been regular and normal. 

Physical examination showed normal temperature, pulse, and res- 
piration, nothing abnormal in the chest, general rigidity of the abdomen, 
especially in the right lower quadrant, where there are marked tender- 
ness and an oval mass, the size of half a lemon, raised above the surface. 

Discussion. — The presence of a raised mass in the region of the 
appendix narrows the field of possibilities considerably. The most 
important differential point in the case seems to me to be the gradual 
onset of the symptoms and signs, without anything that the girl will call 
pain. Appendicitis and pyosalpinx may have a gradual onset, but almost 
never does this occur without marked pain. If these two possibilities 






RIGHT ILIAC PAIN 269 

are for the moment put on one side, we have left ovarian cyst, cancer, 
and tuberculosis of the cecal region and extrauterine pregnancy. If 
we believe the girl's story, the latter is excluded by the regularity of men- 
struation and the absence of pain. Cancer is very rare at her age, and 
should produce symptoms more distinctly referable to the intestine. 
Ovarian cyst cannot be excluded, but there are two points which in- 
cline us to the only remaining alternative, tuberculosis. These points 
are: (a) the occurrence of a pleurisy (/. c, of a tuberculosis) eighteen 
months previously; and (b) the wide distribution of tenderness and 
rigidity over the abdomen. Ovarian cysts generally cause very little 
either of tenderness or of muscular spasm, except in the presence of other 
acute symptoms, such as are absent here. 

Outcome. — The patient was operated on June 23d. A large tuber- 
cular abscess originating in the right tube was drained. 

Diagnosis. — Tuberculosis of right tube. 

Case 135 

A married woman of thirty- nine entered the hospital July 29, 1908. 
Her father died of consumption; one of her sisters is partially paralyzed. 
The patient was a seven-months' baby, and was said to have weighed 
only a pound at birth (? ). She has had measles four times, and many at- 
tacks of grip. A year ago she had an attack similar to the present one. 
She formerly took alcohol in considerable quantities "to give her 
strength," and for six months she has not felt well and has had darting 
pains in various parts of the abdomen, especially in the right iliac region, 
also in the back, knees, and other joints. Three days ago she began 
to have frequent loose, slimy movements, with much pain in the right 
iliac region. The pains in the joints and back have also been increased. 

Physical examination shows a slight systolic thrill at the apex of the 
heart, with a systolic murmur, which, however, is loudei in the pulmonary 
area, and not heard in the axilla. There is no enlargement ; slight general 
abdominal tenderness, more marked in the right iliac region; blood, 
urine, pulse, temperature, and respiration are normal. The stools show 
a few food elements and large amounts of mucus. The patient lies in 
bed with her eves closed most of the time, paying no attention to what 
is going on about her, but complaining of pains indifferent parts of her 

body. 

Discussion. — The suspicion of tuberculosis which is naturalK c\ 
cited when we learn that the patient's father died of consumption 

-light support from any of the other facts in the case. It 
is true that the patient has Blight general abdominal tenderness, but at 



270 DIFFERENTIAL DIAGNOSIS 

no time has there been any fever or any evidence of free fluid or tuber- 
culous masses in the abdomen. Nor do we get any very distinct help in 
diagnosis from the knowledge that she has been alcoholic at times, and 
that she apparently had a very poor start in the world. Possibly her 
alcoholism may have something to do with her mental state or with the 
various pains of which she complains. 

The darting character of these pains and their distribution correspond 
quite accurately with the " lightning pains" of tabes. The physical ex- 
amination as it is here reproduced gives us no evidence wherewith to 
support or to attack this idea, but from my own examination of the case I 
know that all the reflexes were normal. 

The essential symptoms in the case seem to me at the present time 
as follows : Right iliac pain, accompanied by frequent bowel movements 
containing much mucus. Occurring in a patient of the temperament and 
physique which may be inferred from the above description, these symp- 
toms suggest especially the condition known as " colica mucosa" or 
mucous colitis. Three types of this disease are familiar to most prac- 
titioners: (a) Those characterized mostly by pain, with a moderate 
amount of constipation and neurasthenia; (b) those characterized mostly 
by constipation, with a moderate amount of pain and neurasthenia; 
and (c) those characterized mostly by neurasthenia, with a moderate 
amount of constipation and pain. 

In all these cases the stools contain varying amounts of mucus, 
sometimes mixed with fecal matter, sometimes making up practically 
the whole of the dejection. In my opinion, however, the fundamental 
and underlying factor in all cases is the neurasthenic state which is the 
cause of the constipation, and thereby of the pain and mucus. The most 
successful treatment must address itself to the cure of the constipation, 
but this cannot be permanently relieved unless the patient's mental 
habits and point of view can be reconstructed. 

Outcome. — Under treatment for constipation, with 5 grains of 
Blaud's pills three times a day, the patient was discharged relieved on 
the nineteenth of August. 

Diagnosis. — Mucous colitis. 

Case 136 

A school -girl seventeen years old was first seen December 4, 1908. 
Six days before she had a stomachache, which lasted about twenty-four 
hours and then got better. Three weeks before she had had a similar, 
but less severe, pain. Since then she has had similar attacks three or 
four times a day. 






RIGHT ILIAC PAIN 27 1 

On examination the temperature, pulse, and respiration are normal; 
the chest negative, the abdomen level, generally tender, with slight mus- 
cular spasm over the whole right side. 

The last menses came two weeks ago. The diet has been blameless. 
The present attack followed immediately after some high jumping in the 
gymnasium. The pain was almost as great in the back as in front. 
The bowels moved normally during three days of observation. The 
temperature was steadily normal, likewise the pulse. Pain, however, 
persisted and kept her awake most of three nights. At times it was 
rhythmic, coming every fifteen minutes and lasting about two minutes. 
The girl and her family were all well acquainted with the symptoms of 
appendicitis, and much afraid of it. The leukocytes ranged close to 
10,000. Pressure on the left side of the belly caused pain in the appen- 
dix region. Physical examination was otherwise wholly negative. 

Discussion. — The extension of pain and tenderness to the back, 
the absence of temperature, elevated pulse, and increased leukocyte 
count, and the apparent relation to a strain at the time of the onset, 
inclined me at first to believe that this case was due to a wrench either 
of the back muscles or of the sacro-iliac joint. I could not rule out the 
possibility of a pure neurosis, since the patient was an exceptionally 
high-strung and nervous girl, who had known and feared appendicitis 
all her life. Indeed, this diagnosis was furnished to me, ready made, as I 
entered the sick-room. 

But against both these possibilities there was the fact that the pain 
was not relieved either by a complete rest in bed with cross-strapping of 
the back and elevation of the lumbar region on a pillow, nor by repeated 
assurances that she was not suffering from appendicitis. On the con- 
trary, the pain continued with very little abatement. Heat gave it only 
very slight relief; aspirin was equally inefficacious. Judgment was 
still more affected, however, by the pain's rhythmic character, which 
usually indicates spasm produced in some hollow, tubular structure. 
This could not fit in with either of my previous diagnoses, and the verdict 
had to be shifted to appendicular colic. At no time was there any in- 
dication of an involvement of any part of the urinary tract. The pain 
never followed the course of the ureter, nor showed any of the typical 
radiations of nephrolithiasis. The urine remained wholly negative. 

Outcome.- Operation, December 8th, showed an appendix bent 

upon itself, and covered with old adhesions, but not inflamed. 

Diagnosis.- Appendicular colic (chronic appendicitis). 



272 DIFFERENTIAL DIAGNOSIS 



Case 137 



V A Scottish housewife of thirty-five was first seen February 7, 1908. 
Her family history is good, though her mother died of cancer. She 
had polyarthritis, with fever and prostration, seven years ago (soon after 
marriage) . 

For one year she has had nearly constant pain in the right lower 
quadrant of the belly. There is no colic, but the steady pain often needs 
morphin. Pain is relieved by lying down and always disappears at 
night. She sleeps well and has worked until three weeks ago. She is 
not in bed. 

Sometimes the pain extends down the right leg, but it has no other 
radiations. No jaundice. No urinary, circulatory, respiratory, or in- 
fectious symptoms. 

Examination. — No emaciation or anemia. Visceral examination 
was negative except that in the right upper quadrant there was a mass 
palpable bimanually, irregular of surface, descending to the navel with 
inspiration. Tenderness of right lower lumbar muscles. (See Fig. 42.) 
Cutaneous tuberculin reaction negative. 

A catheter specimen of urine showed microscopic blood and pus. 
Cystoscopy showed a normal bladder. Turbid urine was obtained from 
the right ureter; injected into a guinea-pig; five weeks later negative 
autopsy. 

Discussion. — It is noticeable in this case that, although the pain is 
in the right iliac fossa, the tenderness is in the lumbar region, where a 
mass is felt bimanually. The fact that the pain disappears when the 
patient lies down tends still further to connect it with the kidney, rather 
than with any structure in the neighborhood of the cecum. 

Tumors of the kidney produce pain, enlargement of the organ, and 
often a urine such as that here described, but it would be unlikely that 
the amount of pus would be so large in proportion to the amount of 
blood. There has been, indeed, no true hematuria, and after a year's 
duration kidney tumors usually produce a hematuria so profuse as to 
result in anemia. Emaciation would probably be present also by this 
time. 

Renal tuberculosis would explain all the symptoms, though it usually 
does not give rise to such severe and long-standing pain, and almost 
always produces bladder symptoms, which are not complained of here. 
Nevertheless, it is only the results of animal inoculation that enable us to 
exclude tuberculosis in this case. 

Is it possible that a simple looseness and displacement of the kidney 





Fig. 42. — Position of the mass described in Case 137. 



RIGHT ILIAC PAIN 273 

could produce such symptoms? This idea is favored by the disappear- 
ance of pain in the recumbent position, but we do not expect a kidney, 
not in itself diseased, to secrete a urine turbid with blood and pus, al- 
though when the kidney gets in such a position as to twist its blood-vessels, 
we may have hematuria from congestion. The enlargement here present 
seems sufficient to exclude a simple floating kidney. 

The important evidence which we still lack is that obtainable through 
the .v-ray examination of the kidneys with special reference to stone. The 
only point distinctly against stone here is the absence of any colic. The 
good preservation of nutrition is more in harmony with the diagnosis of 
nephrolithiasis than with any other condition producing enlargement of the 
kidney. It is not easy to see just why the kidney should be enlarged as 
the result of stones in the pelvis, unless there were obstruction to the flow 
of urine, a complication of which we have no evidence here. Yet it is 
a very familiar fact that kidneys which turn out to be the seat of no 
disease other than nephrolithiasis uncomplicated, seem considerably 
enlarged when palpated before operation. 

Outcome. — X-ray shows stones in both kidneys. 

Operation : in right kidney a stone with a body the size of a plum 
and three branches one inch long was found; in left kidney three stones, 
the largest as large as a marble, the smallest the size of a marrow-fat 
pea. November 12th: Discharged well. 

Diagnosis. — Stone in both kidneys. 

18 



274 



DIFFERENTIAL DIAGNOSIS 



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Causes of Left Iliac Pain 



°! 



PUS-TUBE AND 
PELVIC ADHE-h 
SIONS 



ECTOPIC GESTA-\ ^^^^ 
TION J ^^~ 29 

DYSMENORRHEA HflBB 24 

OVARIAN CYST) 
WITH TWISTED [■ BHBI 21 

PEDICLE i 

URETERAL STONE B 4 

CANCER OF SIG-1 
MOID J ■ 

Inguinal hernia, the debility of neurotic women, and the temporary 
and atypical localization of some of the causes of diffuse abdominal 
pain are also to be mentioned. 



27H 






CHAPTER IX 
LEFT ILIAC PAIN 

Case 138 

A housewife of forty-six was seen in consultation May 10, 1907. 
The attending physician's diagnosis was cancer of the intestine, probably 
in the sigmoid. The patient has had for three or four years a " stomach 
trouble" characterized by pain near- the left costal margin, with vomiting 
of greenish fluid and "coffee-grounds," the vomitus being sometimes 
sour, sometimes bitter. Vomiting relieved the pain. For the past year 
she has had no vomiting and only moderate soreness in the left side. 
Six weeks ago she felt a sudden knife-like 
pain in the left lower quadrant, which lasted 
twenty-four hours, following which she was 
in bed for five weeks. The bowels moved 
every second day. She has lost five or six 
pounds. 

Physical examination showed fair nutri- 
tion; marked pallor. Red cells, 3,332,000; 
hemoglobin, 50 per cent.; polynuclear cells, 
52 per cent.; considerable achromia; urine 
negative; chest negative. Above and to the 
left of the umbilicus a hard, movable, sausage- 
shaped mass, extending from the median line 
obliquely outward and downward for three 
inches. 

A stomach-tube showed no fasting con- 
tents and no enlargement of the organ. After 
meal, free IICI was 0.28 per cent.; total 
acidity, 0.35 percent. The guaiac test was negative, both in the gastric 
and intestinal content-. 

The diagnosis of cancer of the sigmoid was generally agreed to. 

Discussion. At least three years of a Stomach trouble which has 
produced anemia and hyperehlorhydria, but which has do! led to any 
gastrin such is the background against which the recent symptoms 




. •. Chan of case 1 j8, 



: - 1 duterexhal diagnosis 

of this case stand out. A sudden acute attack of left iliac pain and in 
the same region a tumor, regarding the age of which we have no knowl- 
edge, are the facts which must in some way be woven into a satisfactory 

With such a tumor and such a pain, a diagnosis of sigmoid cancer 
seems at first inevitati a cancer which has existed long enough 

to be palpable as a tumor of this size should also manifest itself by visible 
peristalsis, intestinal noise, gross or occult blood in the stools, diarrhea, 
or marked constipation. That none of these symptoms is present should 
certain!; 9& 

Were the tumor situated higher up in the abdomen, we should 
tainly be inclined h : raider a perigastric exudate resulting from the 
attempt of a gastric ulcer to perforate. The long previous history, the 
present hyperchlor I ae anemia, and the recent acute attack of pain 

are all quite c<: n s is: c n : wi I h : i i ems somewhat remark- 

able, mptoms should have come to so complete a 

standstill as has apparently occurred since the attack /us ago. 

Though nothin g in the text regarding the A pelvic 

examination, I may add here that nothing could be found in the pelvis 
to connect any of its organs with the disease under consideration. 

Outcome. — On the twenty-first of May the abdomen was opened. 
The mass proved to be composed of a ic exudate adherent to 

the a rxiorninal waJL Behir. ic narrow ur:i: :: an hour-glass 

stomach, which barely admitted the little finger and was evidenti 
to the scar of an old gastric ulcer. Gastro-enterostomy was done. Six 
after operation the patient was doing welL 

Diagnosis. — Perforated gastric ulcer. 

Case 139 

A housewife of twenty-six entered the hospital December : - 
For two months she has been having pain in the left iliac region, at 
first darting in character and extending through to the back; later, dull 
and constant, sometimes more severe at night. Pain has been accom- 
panied by weakness and frequent micturition. Her appetite has been 
good, her bowels regular, her urine dark and cloudy for a month. 

The course of the temperature is seen in the accompanying chart. 
The urine was alkaline and contained always a large amo and 

sometimes a great deal of blood in cl 

"eraging about 1012, and the amount of albumin large; no casts 
were ever found. Examination of the chest and abdomen ative; 

fikewi examination of the renal regions. After entrance to the 



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sometimes quite normal, at other times composed 
almost wholly of blood. Several small concretions were passed in the 
early days of January. 19c 7. On the sixth, one obstructed the urethra 
and had to be removed. It was shown to be composed of calcium phos- 
phate upon a nucleus of mucin. Its pas- 
was not attended with pain. Re- 
peated examinations of the urinary sedi- 
ment showed no tubercle bacilli. 

Discussion. — The essential features 
of this case are left iliac pain of two 
months' duration, associated, during the 
month, with the frequent passage 
of an alkaline, cloudy urine cxmtaining 
large amounts of pus and blood. The 
continued fever is also of importance. 

All these symptoms may be produced 
by renal tuberculosis, and this diagnosis 
cannot be possibly excluded upon the evi- 
dence here presented. Animal inoculation 
is necessary. Nevertheless, the absence 
evident enlargement of the kidney, 
demonstrable by palpation or 
amination, the : in alkaline 

urine, and the constant abundance of blood, u vhich tend to 

support the ne§ die search for tubercle bacilli. 

In the hands of a competent operator we may say tft examina- 

tion, declared by him to be negative idence against the 

~al stone. The predominance of bladder symptoms here, 
the absence of anythir. .ohc, and the apparently steady dis- 

charge of blood and pus tend to rule out nephrolithiasis. 

: the kidney rarely produces such a predomin- 
mptoms or so large an amount of pus in the urine. 
neoplasm to be complicated by bladder disease, 
mid not account for the alkalinity of the urine. 

:e in the bladder is rare in women if we leave out of account the 
secondary calculi incrusted about a hair-pin or some other foreign body. 
There is no hist the introduction of any such body in this 

>ry on its - idence a 

stone. In or^ sens sure that stones have been 

in the bladder - raJ small ones have been passed: but from the 

rarity of primary bladder calculi in women and the absenc >f the 



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: 



280 DIFFERENTIAL DIAGNOSIS 

exacerbations due to jolting or moving, we may suppose that the small 
stones which have emerged were formed as a secondary result of some 
other disease. The question remains as to what that disease is likely to 
be. 

Chronic cystitis is now universally recognized to be, in practically 
all cases, a symptom of some deeper cause. The days of primary or 
idiopathic cystitis are passed. Gonorrheal cystitis is distinctly rare 
unless as a part of a much more obvious acute and general infection of 
the genito-urinary tract. 

Tuberculosis of the bladder is a frequent cause of cystitis, and is 
practically always secondary to renal tuberculosis, reasons for excluding 
which have been already given. 

Tumor of the bladder is the only remaining cause of cystitis fre- 
quently occurring in women, and against that diagnosis there seem to be 
no important data. The occurrence of small concretions in and about 
tumor of the bladder is a familiar fact. 

Outcome. — On the twenty-third cystoscopy showed an exceedingly 
foul bladder and a ragged tumor mass on the left side. Operation on 
the twenty-sixth confirmed this diagnosis. A cutting from the mass 
was examined histologically and pronounced undoubtedly malignant. 
The walls of the bladder were much thickened and contracted. 

Diagnosis. — Bladder cancer. 

Case 140 

A laundress of forty-four entered the hospital December 24, 1907. 
She had lost one sister of consumption; her family history was otherwise 
good. She has been subject all her life to occasional sick headaches. 
At half-past nine this morning, while washing, she suddenly began, to 
have steady, severe pain half-way between the navel and the left flank. 
Soon after she vomited her breakfast. The pain was so severe that 
she could not lie down until night. Her suffering has been constant, 
though varying in intensity, and she has continued to vomit a thin, yel- 
lowish fluid. There is some soreness in the region of the pain, but no 
headache at the present time. The bowels moved two days ago with 
medicine, not since. She has been very constipated for years, sometimes 
going a week without a movement. 

Physical examination of the chest was negative save for accentuation 
of the aortic second sound. The urine and blood were normal. The 
right kidney descended two fingers' breadth below the costal margin 
on full inspiration. During the first two days in the hospital the patient 
vomited everything that was taken by mouth. Finally, the bowels were 



LEFT ILIAC PAIN 28l 

started by calomel and enema ta, and by the twenty-seventh the patient 
was taking milk and feeling happy. The first urinary examination 
showed sugar, acetone, and diacetic acid. After that there was no sugar, 
but acetone and diacetic acid persisted until the twenty-eighth. 

Discussion. — The chronic constipation leading to acute pain and 
obstinate vomiting cannot but incline us very strongly toward the diag- 
nosis of sigmoid cancer, especially since the woman is forty-four years 
old. But what are we to say when, after we have made such a diagnosis, 
we succeed in getting the patient's bowels to move naturally and all 
the symptoms disappear? I have introduced this case in order that I 
might emphasize the point that such a recovery by no means excludes 
cancer. In the early stages of that disease, when the growth is little 
bigger than a signet ring, temporary obstruction with fecal impaction 
behind the stricture often leads to symptoms quite like those here de- 
scribed, which, nevertheless, disappear under treatment and may not re- 
cur for weeks or months. It is only by a careful following of the case 
that we can be justified in excluding cancer. 

Outcome. — On the first of January sugar was again present in the 
urine. On the second it was gone and did not return, although the pa- 
tient was allowed a full mixed diet. Thereafter the patient's bowels 
were kept regular by the use of an A. S. and B. pill four times a day. 
There has been, so far as known, no return of symptoms. 

Diagnosis. — Constipation. 

Case 141 

A hostler of thirty-two entered the hospital June 3, 1902. His 
family history and past history were negative. Until the previous 
fall he had always taken five or six beers and three or four whiskies a day. 
He denied venereal disease. Yesterday morning he awoke with a chill, 
chattering teeth, lexer, vomiting, headache, and pain in the left groin. 
He slept poorly last night. The course of the temperature was as seen 
in the accompanying chart. On the sixth the glands were discovered 
to be tender and considerably enlarged in the left groin. There was 
an operation sear over the upper part of the left tibia; the bone under- 
neath it very rough. Below this the skin was bluish red, and several 
ulcerated areas from the size of a silver dollar to that of the palm were 
■ t. An x-ray showed that the tibia was considerably thickened 
in Its upper third, and the fibula throughout ils entire length. Physical 

ination, including the blood and urine, was otherwise negative. 

Discussion. This story seems to narrow itself down to a case of 
with painful glands in tin- groin. ( )ur chief task is to consider the 



282 



DIFFERENTIAL DIAGNOSIS 



probable cause of the glandular enlargement. The ulceration on the 
lower leg may well produce sufficient irritation to stimulate the glands 
into a work-hypertrophy, ordinarily known as a bubo. Leukemia 
being ruled out by the negative result of the blood examination, and 
pseudoleukemia by the absence of glandular enlargement elsewhere, 
it remains only to consider the probable nature of the ulcerations which 

have led to the adenitis and so to the pain 
and fever. 

Ulcerations in this situation are most 
frequently due to the malnutrition following 
varicose veins, hence the term varicose ulcer. 
Next to this, syphilis is the most common 
cause, though it is more apt to produce ulcera- 
tions in the calf or above the knee than upon 
the shin. In view of the #-ray evidence, 
which shows a bony change very commonly 
associated with syphilis, this seems the most 
reasonable diagnosis. 

Regarding the cause of the acute infec- 
tion, with its attendant pyrexia and chill, 
nothing very definite can be said. Possibly 
there was some secondary invasion of the 
tissues induced by a sudden lowering of their 
vitality, for which there are many occasions 
in the life of such an individual. 
Outcome. — Under iodid of potash the glands became smaller, the 
fever went down, the leg ulcers began to heal; on the fourteenth the 
patient was discharged. 

Diagnosis. — Syphilitic adenitis. 



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Case 142 

A housewife of twenty-seven entered the hospital June 21, 1908, for 
pain in the left iliac fossa, her second severe attack within three weeks. 
The first attack (twenty days ago) was very severe, but lasted only about 
one minute. Yesterday at 2 a. m. sudden severe pain began again at the 
same point, lasted until 10 a. m., then suddenly ceased until this morn- 
ing about five, when it returned as she was getting up. At times she has 
seen and felt a swelling in the region of the pain. 

She has had three children, the youngest three months old. Menses 
normal. No other illnesses. 

Examination. — Abdomen prominent in lower left quadrant, where 



LEFT ILIAC PAIX 283 

there are circumscribed dulness and a large, hard, irregular mass, mov- 
able and very tender. It was apparently not connected with the uterus, 
but could be felt per vaginam. Physical examination, pulse, tempera- 
ture, blood, and urine negative. 

Discussion. — The association of left iliac pain with a hard, irregular 
mass in the same region naturally suggests malignant disease. The 
sigmoid flexure of the intestine is the commonest site for such a growth 
in this part of the bod}', and the age of the patient by no means excludes 
this possibility. I have seen a cancer of the sigmoid demonstrated at 
autopsy in the body of a boy who died before his twenty-first year. 
In the present case, however, we have no intestinal symptoms sufficient 
to incriminate the sigmoid, and a growth of the size above described 
would certainly have produced such symptoms if the gut were involved. 

Ovarian tumor seems more probable. We do not expect the com- 
moner varieties of ovarian tumor to be as firm of surface as the descrip- 
tion of this tumor suggests, but I have often been deceived in this 
respect and seen at operations a cystic tumor which felt as hard as a piece 
of wood when examined through the abdominal wall, so that I am no 
longer willing to trust my tactile sensations. Solid tumors of the ovary 
are considerably less common, especially in women of this age, and rarely 
reach so large a size without previously attracting any attention. Fibro- 
myoma of the uterus would probably show an obvious connection with 
that organ and would be less likely to be situated so much at one side. 

Uncomplicated ovarian tumors do not produce acute symptoms like 
those above described, but there are many accidents to which such 
tumors are exposed and by which severe pain may be produced. As 
we have no way, in the great majority of cases, of distinguishing these 
accidents clinically, it is safest to assume that the commonest of them 
— twisting of the pedicle — has occurred. 

Outcome. — Operation showed a gangrenous, strangulated, multi- 
locular ovarian cyst with a double twist in its pedicle and a quart of blood- 
serum in the peritoneal cavity. 

It may be well to mention here some of the varieties in the sympto- 
matology of strangulated ovarian cyst, so as to bring out features not 
exemplified in the case just discussed. 

(a) In many cases then; are repeated attacks which arc clinically 
similar in type, but lesser in intensity than that above described. Many 
of these attacks arc. due, doubtless, to patches of local peritonitis such as 

It in the adhesions which often confront the operator years later. 

(b) General abdominal tenderness and spasm, associated with vomit- 
ing and great prostration, often make the clinical picture much like that 



284 DIFFERENTIAL DIAGNOSIS 

of acute peritonitis, which can be excluded only when the patient or her 
physician has previously known of the tumor's existence. 

(c) Tumors occupying the right side of the abdomen are fully as 
common as left-sided growths. In a considerable proportion of cases the 
cyst is to be found in the median line, and the diagnosis is thereby con- 
siderably obscured. 

(d) Moderate fever and leukocytosis are the rule, the former ranging 
between ioo° and 102 in most cases, while the leukocytes are usually 
between 14,000 and 20,000. 

(e) If menstruation occurs during such an attack of pain, the latter 
is often relieved. 

Diagnosis. — Multilocular ovarian cyst (twisted pedicle). 

Case 142a 

A widow of sixty-seven called her physician in September, 1908, 
on account of pain in the left iliac fossa. For five or six years she has 
noted a bloody discharge with some odor. This discharge has been 
supposedly due to hemorrhoids and has been treated as such, but 
examination now shows it to come from the vagina. For the past 
week this discharge has been active and the blood has been bright. 
Four weeks previously to this time she had a week's flowing, and 
similar periods have occurred from time to time during the last five 
years. 

The present illness began three weeks ago with pain, tenderness, 
and enlargement of the left lower quadrant of the abdomen, accom- 
panied by fever which averaged 101 F. for the first week of her 
illness. This gradually fell to normal, so that ten days ago the 
local physicain was able to discontinue his visits for three days. 
With the subsidence of temperature the weakness, tenderness, and 
pain of which she had previously complained gradually disappeared, 
but a week ago all the symptoms returned, and during the last six 
days fever has averaged ioo° F. The pain is now referred not only 
to the left iliac fossa, but to the left thigh and hamstring muscles. 
The bowels are moved by enema. 

The appetite has been very poor and there has been marked 
prostration, so that she has been in bed most of the time during the 
last four weeks. Her weight has fallen considerably. There has 
been no vomiting, no cough, and no pain other than that described 
above. The menopause occurred thirteen years ago. 

When seen in consultation October 19, 19 10, the patient's tern- 



LEFT ILIAC PAIN 285 

perature was 101.2; there was moderate emaciation; at the apex of 
the right lung the physiologic peculiarities of that space on auscul- 
tation and percussion seemed somewhat exaggerated. Otherwise 
the chest showed nothing abnormal. The left lower quadrant of the 
abdomen was tilled by a smooth, resistant, apparently elastic mass, 
protected by a considerable amount of muscular spasm and rather 
tender. The same- mass was felt by vagina, but seemed to be un- 
connected with the uterus, which was normal. 

The leukocytes numbered 25.600, 90 per cent, of which were 
polynuclears. There was no anemia. The urine was normal. 

Three weeks later the attending physician reported that the 
patient was about the same, the temperature still reaching about 
101 F. each night, being normal or subnormal in the morning. There 
was then very little pain and the vaginal discharge had ceased. 

Discussion. —Cancer of the uterus was first suspected on ac- 
count of the ill-smelling vaginal discharge. That this was not of 
the ordinary type, involving the cervix uteri, was readily shown by 
the vaginal examination. Cancer of the body of the uterus was not 
excluded, as no intra-uterine examination was made. It is ve ry 
unlikely, however, that so much fever and left iliac tenderness would 
be produced by a neoplasm of the body of the uterus. 

Cancer of the sigmoid was next considered. The position of the 
tumor mass, the age of the patient, and the presence of a bloody dis- 
charge, which the patient believed to have come from the rectum, 
favored this diagnosis. On the other hand, nothing definite could be 
felt by rectum. There was no evidence of intestinal obstruction and 

I no diarrhea, while the presence of continued fever for more than a 
month made uncomplicated neoplasm very unlikely. The same 
holds true of ovarian neoplasm. Pyosalpinx nsidered, but 

seemed exceedingly unlikely in view of the pal and char- 

Diverticulitis is strongly suggested by all the facts of the case. 
The age of the patient, the position and consistency of the tumor, 
and the continu >\ fever with leuko .ire typical. 

Outcome. On operation, November [3th, a Large inflammatory 
mass wa- found ler th bladder, the lower sigmoid, and the 

Ijoining part-. In thi center of the mass, close to the sigmoid, a 
1 ontaini] ablespoonful of pus was found. Lead 

inu 1 onnecting with the interior of the 
which was greatly thickened and infiltrated for a 
nee above and below the -inn.-. Microscopic 



286 DIFFERENTIAL DIAGNOSIS 

examination later showed that the sinus originated in a diverticulum. 
The pus was evacuated and drained, a portion of the sigmoid resected, 
and an end-to-end suture done. The patient made a somewhat slow, 
but uninterrupted recovery. 

Diagnosis. — Diverticulitis of the sigmoid. 

GENERAL CONSIDERATIONS ON THE DIAGNOSIS OF ABDOMINAL 

PAIN 

Though I have followed current practice in separating the causes of 
localized from those of generalized abdominal pain, it must be admitted 
that the separation is not always true to fact. Diseases like appendi- 
citis, whose pain belongs in the right iliac fossa, are very apt to set their 
pain loose all over the belly. On the other hand, lead-poisoning, which 
usually causes wide-spread "dry" bellyaches, may anchor its colic to 
a single spot in a most misleading way. 

Hence one who looks under one chapter for some familiar type of 
pain may wonder at its absence and be surprised to find it in another. 
Some causes of suffering, on the other hand, are listed under two different 
headings (e. g., ectopic gestation, strangulated ovarian cyst), because 
they are about equally common on the right and on the left. 

When searching out and thinking out the probable cause of an ab- 
dominal pain we are all guided, I take it, by the following obvious rules: 

i. Suspect, first of all, the gastro-intestinal tract, and if its simpler 
troubles (such as constipation and colitis) can be excluded, consider 
especially appendicitis, peptic ulcer, neoplasms of the stomach or large gut, 
and the remoter consequences of these lesions (peritonitis, intestinal 
obstruction). 

2. Suspect next (in women) the genital tract (pus-tube, ovarian cyst, 
uterine fibroid, ectopic gestation). 

3. The gall-bladder and its ducts are especially to be considered if 
the patient is past middle life. 

4. The urinary tract, especially in elderly men or young girls, comes 
next in the order of causes for abdominal pain. 

In investigating any of these causes the history, palpation, the blood, 
the urine, x-ray, and cystoscopy a. e the most valuable aids. 



LEFT ILIAC PAIN 



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CHAPTER X 



IIW 




AXILLARY PAIN 

Case 143 

A stableman of .thirty-nine entered the hospital January 24, 1908., 
with negative family history and good habits. Past history uneventful 
except for an attack of malaria in September, 1907. Three days ago, 
while at work, he had a severe chill. He went home, but did not go to 
bed. The next morning he went to work as usual, but had to give up 

about noon and take to bed, where 
he has remained since, with head- 
ache, high fever, pain in the left 
chest, sore throat, nausea, thirst, 
and frequent vomiting. His 
bowels were moved by laxatives 
this morning. When he swallows, 
he sometimes feels a sharp pain 
which shoots from his throat to- 
ward his left ear. 

The patient's temperature is 
seen in the accompanying chart. 
At entrance he was breathing 
easily, and there was no motion 
of the nostrils. He complained 
of deafness and buzzing in his 
ears, especially the left. There 
was internal strabismus on the 
right, which he says is of long 
standing. There was a mild spasmodic cough, but no sputa. Visceral 
examination was negative, save that in the lower left back there was a 
little dulness, and the voice-sounds were a trifle nasal in character. 
Just below the scapula the breath-sounds were somewhat diminished, 
whispered voice slightly increased, and an occasional clicking rale was 
audible. No bronchial breathing. 

The white cells were 20,000; urine, 32 ounces; specific gravity, 1023. 
There were a few hyaline, many fine granular casts, and a slight trace of 
albumin. 



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Fig. 46. — Chart of case 143. 



Causes of Axillary Pain 



1. FLATULENCE LEFT AXILLA AND PRECORDIA 



pleurisy m^a^mmmBBmmmmm^mmam^mm^m 1013 

PNEUMONIA ■BnBBHHHHDHBH 

4. FRACTURED RIB ^HH 234 

5. INTERCOSTAL \ 48 

NEURALGIA J 

6. RADIATIO NS1 

FROM HYPER- 

TROPHIC^ ■ 45 

SPINAL AR- l 

THRITIS J 

Among other lesions not graphically represented here, because of 
their rarity as causes of axillary pain, are : 

Herpes zoster. 
Costal tuberculosis. 
Costal neoplasm. 
Costal actinomycosis. 
Angina pectoris. 
Deep axillary abscess. 
Fractures and dislocations of the shoulder and humerus often pro- 
duce axillary pain, but usually present no diagnostic difficulties so far 
as the source of the pain is concerned. 

Finally, there is a large group of axillary pains, apparently of mus- 
cular origin, akin to lumbago and " stiff neck." The bombastic term 
■ pleurodynia" is often attached to these pains, but since their actual 
nature is unknown and their diagnosis never certain, I have attempted 
timate of their relative frequency. 









AXILLARY PAIN 2CjI 

Discussion. — Obviously, we are dealing with an infectious disease, 
though gastric symptoms occupy the foreground of the clinical picture. 
For simple tonsillitis the patient is apparently too sick, and there was 
nothing in the tonsillar region sufficient to justify the diagnosis. 

The deafness, the buzzing sounds, and the shooting of pain toward 
the ear might indicate otitis media, but unless pain is more definitely 
localized and continuous in or about the ear, one could not make such a 
diagnosis in the absence of any discharge or any knowledge of the con- 
dition of the drum membrane. 

Acute meningitis may begin in this way, and there is nothing said 
in the text regarding the condition of the neck muscles or of the ham- 
strings (Kernig's sign). The strabismus would be of great diagnostic 
importance if we disregarded the patient's statement that it has existed 
for many years. As a matter of fact, however, investigation showed that 
there was no stiffness of the neck or of the ham-string muscles. Without 
lumbar puncture no further certainty can be obtained on this point, 
and meningitis must remain a possibility unless we can find some more 
plausible explanation for the symptoms. 

It was subsequently learned that the patient had been given large 
doses of quinin before he entered the hospital, the chill and the previous 
attack of malaria having led to the exhibition of this drug. 

Although the pulmonary signs are very slight and not distinctive, 
they seem to me sufficient to warrant a diagnosis of pneumonia when 
we link them with the continued fever, the leukocytosis, the chest pain, 
the chill, and the gastro-intestinal symptoms. Cases of pneumonia 
which do not show early and well-marked signs of pulmonary solidifi- 
cation are very apt to begin with several days of gastro-intestinal symp- 
toms, the significance of which would be very obscure but for their 
association with fever and leukocytosis. 

Outcome. — Rusty, tenacious sputum was later raised, and in it 
the pneumococcus was the predominating organism. 

At no time were the siims in the chest any more definite than at en- 
trance. On the twenty-sixth there were moist rales in various parts 
of the lun^s, and the patient was somewhat delirious. On the thirty- 
the day after the crisis, then,- was a friction rub in the sixth left 
. anterior axillary line. 

On the twelfth of February the patient left the hospital perfectly 

well. 

The treatment consisted of laxatives, a tight swathe, ice bag, and 

hot-water bottle for pain, and an occasional dose of morphin. 
Diagnosis. Pneumonia. 



292 DIFFERENTIAL DIAGNOSIS 

Case 144 

An Italian farm-laborer, sixty-six years old, was first seen January 
30, 1908. His family history and past history were negative, his habits 
good. Seventy-two hours ago ; while standing on a chair to put a cloth 
over his canary's cage, he lost his balance and fell to the floor, striking 
his left side on the back of the chair. He was unconscious for some 
minutes, and later experienced a sharp pain in the left side of the chest, 
worse on coughing or deep breathing. This pain has troubled him 
ever since, and has been accompanied by a slight dry cough. For two 
days he has been feverish. 

At entrance, the patient's temperature was 99.4 ° F.; pulse> 79; res- 
piration, 20. There was a marked posterior convexity of the lower 
dorsal and upper lumbar spine. The breath was foul. There was a 
slight, diffuse, systolic pulsation under each clavicle, especially on the 
left. The heart was negative. Scattered throughout both lungs were 
squeaks and crackles. There was marked tenderness over the eighth 
and ninth left rib in the midaxillary line. Pressure over the vertebral 
end of the ninth rib caused pain over the same rib in the midaxilla. No 
definite crepitus was obtained. A rough grating was heard with inspira- 
tion in the painful area. At the top of the left axilla was a suggestion 
of bronchial breathing. On the left forefinger and the back of the last 
phalanx was a raised, reddened, tender area, half an inch in diameter, 
crusted in the center. From this a little seropurulent fluid could be 
expressed. He has had this trouble for a month. The next day the 
fluid in this lesion was distinctly purulent. 

Discussion. — Fever, cough, rales, and axillary pain in a man of 
sixty-six lead straight to the diagnosis of pneumonia if we are in the habit 
of judging by symptoms alone, and so far as the pulmonary signs are 
concerned, they are perfectly consistent with the existence of a central 
pneumonia or of pneumococcus infection which has not yet become 
localized anywhere. More important evidence against pneumonia is 
furnished by the temperature chart, the low respiration rate, and the 
absence of gastro-intestinal symptoms. Up to the time when I saw the 
patient no leukocyte count had been made, and as this seemed to me 
one of the most important diagnostic data, I made the count at once. 
There were 6500 leukocytes per c.mm. So low a count rarely occurs in 
pneumonia unless the patient is more ill than this man seemed to be. 

The pulsations beneath the clavicles had given rise to considerable 
anxiety in the mind of the attending physician, who thought they might 
be connected with an aneurysm, which he suspected of producing pain 






AXILLARY PA IX 293 

in the side. But there was really no evidence of aneurysm, and the 
pulsation was not greater than is often seen in thin persons whose sub- 
clavian arteries happen to lie near the surface. 

Of pleurisy there were no certain physical signs, and although this 
diagnosis is often made on the basis of the patient's account of his pain, 
and often definitely at his suggestion, experience does not justify any such 
diagnosis. Many patients and not a few physicians allow themselves 
to speak of "pleurisy pains" when they would not seriously maintain 
that they had evidence of any form of pleurisy. The rough grating 
sound referred to was probably due to another cause, soon to be men- 
tioned. 

Pain of muscular origin — the so-called pleurodynia — akin to stiff 
neck and lumbago — must be shown to vary directly with the amount of 
muscular motion; apparently there was no such variation. Pleurodynia 
produces general widespread tenderness, much less local than was 
present in this case. 

The protuberance of dorsal and lumbar vertebrae makes us ask whether 
any form of spondylitis may be responsible, through radiations along 
nerve-roots, for this patient's pain. Pain of this type is often made worse 
by coughing or deep breathing. It does not, however, lead to tenderness 
in midaxilla, and would be very unlikely to appear suddenly after a fall. 

The fact that pressure on the ninth rib near the spine produces pain 
localized in the axillary portion of that rib is strong evidence that that 
rib is cracked, and the local tenderness and the rough grating sound 
following such a fall point strongly in the same direction. In the ab- 
sence of crepitus no further evidence can be obtained, unless a callus 
forms. This diagnosis would doubtless have been made at the start had 
not the patient chanced to be feverish. Presumably the fever was due to 
the slight infection on the forefinger. 

Outcome. — The chest was strapped with plaster and in two days 
the patient was well enough to go back to work of a light character. 

Diagnosis. -Broken rib. 

Case 145 

A housemaid of twenty five entered the hospital July 20, igo6. 

line days ago she suddenly experienced sharp, shooting pain in the lower 

"ibs and in the right axilla, not worse on cough nor on deep breathing. 

"his pain lasted one day; she then began to have pains in her head and 

, with fever, chill, and genera] weakness. Four days ago she had 
e up and go to bed. Her bowels have moved regularly, but Bhe 
vomited once. 



294 



DIFFERENTIAL DIAGNOSIS 



Physical examination was entirely negative. 

The white cells were 2500; no Widal reaction; urine normal, except 
for the presence of a diazo-reaction. 

The course of the fever is shown in the accompanying chart. 
Discussion. — At the outset it was impossible to exclude pneumonia, 
although the association of so low a white count with a good general 
condition seemed very much unlike pneumonia. Had the leukocyte 
count been high, I should have suspected pneu- 
monia, present or to come, even in the absence of 
definite signs in the chest. 

I have known a case altogether similar to this to 
be counted among the successes of a physician who 
thought he could abort typhoid fever. It is true 
that typhoid fever not infrequently shows under 
observation no longer a period of pyrexia than was 
here recorded, but the presence of a diazo-reaction 
is by no means sufficient evidence on which to base 
a diagnosis of typhoid under these conditions. 
Only by the demonstration of typhoid bacillus or 
at least of a well-marked Widal reaction can the 
diagnosis be justified when the fever is so brief. 

Pleurisy is excluded by the short duration of the 
pain and by the absence of physical signs. 

I have known tertian malaria to produce symp- 
toms strikingly like those with which this case be- 
gan, but the pain and fever were then much more 
definitely intermittent and did not cease permanently until quinin was 
given. In the case here under consideration no quinin was exhibited. 

It is the fashion to call such cases as this "grip" or "influenza," 
but although these words are not taken very seriously by the physician 
who makes the diagnosis, they seem to me sufficient to mislead the patient, 
and incidentally the physician himself. They hide from us the fact that 
we are facing something which we do not understand. A well-known 
name easily transforms itself into the impression that we know some- 
thing of the disease to which we are applying it. This tends to make 
progress impossible. It seems more sensible to recognize that the un- 
named infections are probably as numerous as those already listed and 
named in our text-books, and that in a case like this we are confronted 
with one of this unnamed and unknown multitude. 

Outcome. — In six days the patient seemed perfectly well; the treat- 
ment consisted mainly of an occasional laxative and hypnotic. 
Diagnosis. — Unknown infection. 



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Fig. 47. — Chart of 
case 145. 



AXILLARY PAIN 295 



Case 146 



A master painter of sixty entered the hospital November 18, 1907. 
His family history was good. From the age of sixteen up to the age 
of thirty-two he suffered from neuralgia in the right side of his forehead, 
but was finally cured in 1879. He had typhoid at eighteen, just after the 
Civil War. Twenty years ago he was laid up for six weeks with lum- 
bago, and has had several less severe attacks of this pain since. He has 
never had lead colic, nor any pain in his joints. His habits are good. 

For six years he has been troubled with pain in the left upper chest, 
the attacks gradually growing worse and more frequent. Now the pain 
is nearly constant unless he takes medicine. The pain is of three sorts: 
(1) A dull, burning pain, present in the chest most of the time; (2) a 
terribly severe pain, with a feeling as if he were gripped in a vise. This 
comes from once a week to once a month, and has several times waked 
him in the night. (3) A sharp, shooting, knife-like pain, beginning in 
his left chest, running up to his shoulder and neck, and sometimes felt 
also in his arms. This comes at irregular intervals — more often within 
the last two or three years. There are no gastric symptoms. The pain 
does not seem to have any relation to food. There is no dyspnea, cough, 
palpitation, or edema. Years ago exertion seemed to make him worse, 
but now, he says, it seems to make him better, and lately he has dreaded 
bed-time. He has been treated in the out-patient department since 
May, 1902. He still directs his business and works irregularly. 

Physical examination shows an obese man, with normal tempera- 
ture, pulse, and respiration; the blood-pressure, 150 mm. The urine 
averages 40 ounces in twenty-four hours; specific gravity, 1027; no al- 
bumin and no casts. The white corpuscles range between 12,000 and 
14,000 per c.mm. No stippling of red cells. No lead-line. 

The first sound at the heart's apex is followed by a soft murmur, 
best heard in the aortic area, not transmitted to the axilla. The aortic 
second sound is greatly accentuated. There is no demonstrable cardiac 
enlargement. The pulses are equal and regular, the artery wall not 
remarkable. 

Physical examination is otherwise negative, except that there is some 
dulness in the Hanks, which, however, shows no shift attendant upon 
change of position. 

Discussion. When a house-painter complains of a pain of any kind, 
our knowledge of the pathology of lead poisoning naturally leads us 

to do what we can to connect the pain with the patient's occupation. 
In this case, however, there is no definite evidence of lead poisoning 



296 DIFFERENTIAL DIAGNOSIS 

(stippling is often present in lead-workers who show no evidence of ill- 
ness), and the pain is not such as we are accustomed to see produced by 
that disease. 

The previous history of lumbago makes us seek to find evidence of 
that disease in the patient's present symptoms, but there seems to be no 
such close relationship between the pain and movement of the affected 
muscles as would be expected in lumbago. 

The situation and continuity of the pain are such as we are accustomed 
to associate with aortic aneurysm, and only by x-ray examination (which 
was not made, owing to the patient's poor condition when he first entered 
the hospital) can aneurysm be positively excluded. 

Angina pectoris produces pains the character and location of which 
correspond accurately with those here described. The patient's state- 
ment that exertion now seems to make him better is practically the only 
consideration that seems to contradict this diagnosis, and this is not 
sufficient to exclude it. As to the nature and prognosis of the affection, 
our judgment would be much assisted if we knew whether the patient 
was an excessive consumer of tobacco. No further certainty can be 
obtained without the therapeutic test (nitroglycerin or amyl nitrite) and 
an x-ray examination. 

Outcome. — He has used nitroglycerin in doses of t ^q grain from the 
first, and for years a single tablet gave prompt relief. Gradually the 
necessary dose has increased, until of late he takes as much as -fifa in 
twenty-four hours. 

X-ray showed no evidence of aneurysm. During the patient's stay 
in the hospital he usually had an attack each night, best relieved by 
amyl nitrite. Sitting up or walking about the ward seemed to bring on 
attacks, relieved in the same way." 

On the second of December he was discharged not relieved. 

Diagnosis. — Angina pectoris. 

Case 147 

A French-Canadian cabinet-maker of thirty-six entered the hospital 
November 3, 1906. His family history and past history were not remark- 
able, but he has used a great deal of tobacco and taken three or four 
drinks of hard liquor every day for fifteen years. 

Five years ago he began to have pain in the left side of the chest and in 
the pit of the stomach, brought on by exertion or excitement, gradually 
increasing in frequency and in severity. The pain stabs like a knife, 
lasts about half a minute, makes him stop whatever he is doing and stand 



AXILLARY PAIN 297 

bracing himself back. Occasionally it comes on at night, and then 
he has to sit up in bed " holding onto himself." 

Last winter he began to have palpitation and dyspnea on exertion. 
Four months ago he stopped work by his physician's advice and went 
into the country, following which he promptly became worse and for a 
time could not sleep on less than four pillows. His abdomen also swelled, 
and the upper part of it was tender. These symptoms have now so 
far subsided that he can sleep on one pillow. Two or three years ago 
his wife noticed that one pupil was larger than the other. He has lost 
twelve pounds in the last three years. 

On physical examination the above observation regarding the pupils 
was confirmed. Both were slightly irregular in outline, but reacted 
normally. The heart's impulse was in the sixth interspace, if inches 
outside the nipple. A systolic murmur was heard, loudest at the apex, 
transmitted also over the whole precordia and into the axilla. In the 
axilla and back, a harsh diastolic murmur was also heard replacing the 
second sound. Xo second sound at all was heard in the aortic area. The 
pulse was of the Corrigan type. The systolic blood-pressure was 165 mm. 
The daily amount of urine averaged 30 ounces, with a trace of albumin 
and no casts. At times a presystolic rumble was heard at the apex. 
During the first ten days' stay in the hospital he was given magnesium 
sulphate, an ounce every morning, tincture digitalis, 10 minims every 
six hours, iodid of potash 10 grains four times a day, y^ grain of nitro- 
glycerin when needed. His progress during this period was uneventful. 
On the night of the fourteenth he was rather uncomfortable. On the 
fifteenth he vomited several times. His pulse was more rapid and 
weaker. 

Discussion. — The pain is strongly suggestive of angina pectoris, but 
the patient seems rather young for the organic type, dependent on arterio- 
sclerosis, and too ill for the functional type. As in the previous case, 
we are unable to exclude aneurysm, as the patient is too ill to be moved 
to the .v-ray room. The pain and the inequality of the pupils remind 
us distinctly of that diseas 

As regards the type of cardiac lesion, there seems to be distinct evi- 
• of aortic insufficiency with hypertrophy and dilatation of the 
heart. In a patient of this age the occurrence of aortic disease with no 
preceding rheumatic attacks justifies us in treating the case as one of 
typhi! ially when the cardiac lesions are associated with irregular 

and unequal pupils. This assumption rests upon the fact that syphilis 

of the cardiovascular system usually begins in the arch of the aorta and 

ds thence to the aortic val 



298 DIFFERENTIAL DIAGNOSIS 

Outcome. — About 7 p. m. he remarked that he had had rather an 
uncomfortable day, and felt that it was his duty to stay in bed, but that he 
hoped to be allowed to get up the next day. About 8 o'clock be became 
unconscious and died within a few minutes. 

At the autopsy (No. 181 6) no cause for the suddenness of death was 
discovered. The heart was greatly dilated and hypertrophied. There 
was a chronic fibrous myocarditis, and the heart-wall was much thinned 
near the apex of the left ventricle. There was stenosis of the coronary 
orifices and a fibrous deformity of the aortic valve. Just above the aortic 
valve, and in the arch of the aorta, were very many fibrous plaques. A 
chronic pleuritis and chronic perihepatitis with adhesions was also 
found. 

Microscopic examination of the aortic wall showed a number of the 
organisms of syphilis (treponema pallidum). 

Diagnosis. — Syphilitic heart and aorta. 

Case 148 

A Jewish laborer of nineteen entered the hospital November 4, 1907. 
His family history and past history were good, also his habits. In Feb- 
ruary, 1907, he began to have a loud, ringing, brassy cough, and to raise 
considerable sputa. At the same time he had hoarseness and pain in 
the left upper chest, both front and back. He improved at first, later 
losing all he gained. Yet he has felt less thoracic pain of late, although 
he has coughed considerably. Three days ago, following a severe par- 
oxysm of coughing, he was seized with intense pain in the left lower chest, 
both front and back. The pain has gradually improved since, but is still 
severe on coughing. During the same period he has been somewhat 
short of breath — a new symptom for him — and has felt feverish. 

The movement of his temperature, pulse, and respiration is seen in the 
accompanying chart (Fig. 48). The iris of his left eye is bluish; of the 
right, brownish. The right pupil is smaller, markedly irregular, and situ- 
ated more toward the inner side of the eye. The vision of this eye is much 
diminished. The right border of the cardiac dulness extends 3} inches 
beyond the midsternal line, and reaches a point just inside of the right 
nipple. The left border of dulness extends about an inch beyond the 
midsternum. The cardiac sounds are best heard in the second and 
third right interspaces. Here the rhythm is fetal; the sounds sharp and 
clear. To the left of the sternum they are difficult to hear. The left 
chest is hyperresonant throughout, while the right is somewhat dull. 
Breath-sounds are markedly diminished on the left, increased on the 




Fig. 49. — Physical signs in Case 148. Cough, fever, and a sudden attack of pain in the 
lower left axilla are the chief complaints. 




Fig. 50.— Physical signs found posteriorly in Case 148. (See also Fig. 48.) 



AXILLARY PAIN 



299 



right. Tactile and vocal fremitus are almost absent on the left. Physi- 
cal examination of the abdomen and the rest of the body is normal. 

By the seventeenth of November the patient was much more com- 
fortable, though the physical signs had not changed. At the apex of the 
left lung a few line moist rales were heard, with distant bronchial breath- 
ing and slight dulness (Fig. 49). 

A -ray revealed a shadow in the left chest about the level of the angle 
of the scapula. There were evidences of fluid below this point. 

Discussion. — Although fever, chest pain, and cough are so often the 
precursors of pneumonia, these symptoms have lasted far too long, in 
the present case, to be at all typical, and as soon as we scrutinize the de- 




Fig. 48. — Chart of case 148. 

tails revealed by physical examination, it is obvious that the picture is 

quite unlike that of pneumonia. 

The extension of dulness, continuous with that of the heart's area 

to the right of the sternum, the hoarseness and brassy cough, and the 

pain in the chest suggest aneurysm. But the pain is on the left, and the 
-ion of cardiac dulness on the right. There are no pressure signs, 
'ions, or a* ray shadows to support the suspicion of aneurysm; 

only the patient's complaints are favorable to that diagnosis. 

When the heart is displaced to the right, as seems to be the ease here, 
iturally investigate the causes of this displacement, beginning with 
immonest —left pleural effusion. In favor of this condition we have 

the diminution of respiratory murmur and the absence of voeal and tactile 



300 DIFFERENTIAL DIAGNOSIS 

fremitus in the left chest. But in spite of these signs, pleural effusion, 
serous or purulent, may be unconditionally excluded on the evidence of 
a single sign, viz., the hyperresonance of the whole left chest. Hyper- 
resonance of a portion of one chest — for example, the lower axillary 
region or the upper quarter — is quite consistent with pleural effusion, 
but total hyperresonance has never been recorded, so far as I know, 
with pleural effusion. Over a pneumonic consolidation situated deeply 
in the lung substance the percussion-note is not infrequently hyperres- 
onant or tympanitic, but this never occurs, I believe, throughout a chest 
containing a pleural effusion. Hyperresonance of one chest then, with 
displacement of the heart toward the opposite side, is practically distinc- 
tive of pneumothorax, which seems the reasonable diagnosis of this 
case. 

Emphysema produces general hyperresonance, but it is never uni- 
lateral, never dislocates the heart, and never causes pain. 

The prolonged cough, with the rales and dulness at the apex of the 
left lung, are presumably due to that disease which almost invariably 
underlies pneumothorax — phthisis. The x-ray shadow and the evi- 
dences of fluid which gradually developed at the base of the left chest are 
doubtless due to the accumulation of an exudate, converting the pneu- 
mothorax into hydropneumothorax according to the ordinary rule. 

Some account of the two main clinical types of pneumothorax has 
already been given. Hence nothing further is added here. 

Outcome. — The sputum contained many tubercle bacilli. A suc- 
cussion splash was once made out. 

On the nineteenth of December there was still no change in the pa- 
tient's condition so far as the signs in the chest were concerned; the 
patient was feeling much better, had gained considerably in weight, and 
had almost no cough. On the twenty-first of December he was allowed 
to go home. 

Diagnosis. — Pneumothorax (pulmonary tuberculosis). 

Case 149 

A teamster of fifty-two entered the hospital April 3, 1908. His 
family history and habits were good. He had right-sided pleurisy in 
1872, and was in bed ten weeks with fever and pain in the chest. He 
was not tapped. Since then he has been well. In October, 1907, he 
was struck on the right chest by a roll of cotton duck weighing 400 pounds. 
He had some pain there, which went off after a few days. He thinks 
no ribs were broken. Three weeks ago he began to have dull, constant 
pain in the right chest, worse on deep breathing. This pain lasted a week. 



AXILLARY PAIN 301 

March 30th he went to work, but the pain soon returned and compelled 
him to stop work. Now that he is in bed he has practically no pain, no 
cough, no fever, an excellent appetite, and feels in most respects very 
well. 

His temperature, pulse, and respiration are normal, likewise his 
blood and urine. He lies comfortably in bed without dyspnea. His 
heart is negative. The artery walls are tortuous, with visible pulsation 
in the radials, brachials, and axillaries. The right chest is flat below the 
fourth rib in front and midscapula behind. Over this area respiration 
is absent, likewise voice and fremitus. 

Discussion. — As this patient has previously had pleurisy on the right 
side, we need to consider whether the organized results of that attack — 
pleural adhesions — might account for the symptoms which are now 
present. I should say decidedly not. An inflammation which has en- 
tirely died out thirty-six years earlier does not lead to acute pain. The 
pain of a pleural effusion may linger on for months, or even for a year or 
two, but never for thirty-six years. Pleural adhesions may cause dul- 
ness and diminished breathing, but not flatness and absent breathing. 

Can the trauma of October, 1907, be the cause of the present trouble? 
The interval of five months between the time of the blow and the onset 
of the present pain makes this rather unlikely. Hemothorax never 
results, so far as I know, from an injury of this kind without fracture of a 
rib or puncture of the pleura. Serous pleurisy has also, in my opinion, 
no connection with such an accident. 

Dropsical effusions due to disease of the heart or kidney have a 
predilection for the right chest, but we have no evidence of any such 
disease in the present case, although there appears to be some arterio- 
sclerosis in the peripheral vessels. Further, dropsical effusions do not 
produce pain. 

These alternatives can be easily excluded, and the diagnosis of pleural 
effusion is then so automatic that it may be questioned whether I am 
justified in introducing this case in a book supposed to deal with diag- 
nostic difficulties. On this point I can only say that I have repeatedly 
seen in consultation cases of serous pleurisy which had not previously 
been recognized because the patient had complained so little of the chest 
that no thorough physical examination had been made. Under these con- 
ditions the diagnosis is usually "typhoid," "slow fever," " autointoxica- 
tion," or " ptomain-poisoning." 

It is worth while to note in passing that this patient was in bed 
ten weeks with his untapped pleurisy of 1872, whereas in [908 his illness 
than two weeks. 



3° 2 DIFFERENTIAL DIAGNOSIS 

Outcome. — A paravertebral triangle was demonstrated, its dulness 
3 inches wide at the base. The right chest was tapped, and 32 ounces of 
fluid obtained. Specific gravity, 1017; albumin, 2.7 per cent.; lympho- 
cytes, 87 per cent. 

The fluid did not reaccumulate. On April 9th he was discharged 
well, with the caution that he must always be rather more careful than 
other men as regards fresh air (day and night), regular meals, and the 
avoidance of all excesses. 

Diagnosis. — Pleural effusion. 

Case 150 

An Italian housewife of thirty-five entered the hospital April 25, 
1907. Three years ago she had an operation, following which she has 
had no menstruation, but frequent "hot flushes" rising from the ab- 
domen to the head, accompanied by sweating and headaches which 
sometimes "made her crazy." During the past five months she has had 
frequent attacks of pain in the epigastrium and left chest. The pain is 
never severe enough to make her lie down. It lasts sometimes most of the 
day. It sometimes runs down the inner side of the left arm to the finger- 
tips. The pain comes on suddenly, feels like needles pricking the skin, 
and is often accompanied by a sensation of heat all over her abdomen. 
Her urine scalds her during micturition. 

She has worked up to the time of entrance, although she eats and 
sleeps poorly and her bowels are costive. 

Temperature, pulse, and respiration are normal. Physical exam- 
ination of the chest and abdomen is wholly negative. There is a thin, 
yellowish, vaginal discharge. The urine shows considerable pus. 

Discussion. — Everything inclines us to explain many of the symp- 
toms in this case as the result of an artificial menopause. We must make 
sure, however, that the familiar and typical phraseology used by such a 
patient does not sometimes mislead us into overlooking some deeper 
organic disease, such as pulmonary tuberculosis. If this occurs to us 
as a possibility, the use of a thermometer will soon make clear in the 
vast majority of cases that there is no fever, the sweating and sense of 
heat being due to vasomotor changes. 

The presence of pus in the urine makes it reasonable to inquire 
whether some local infection of the genito-urinary tract may not be con- 
nected with the cardiac symptoms, since gonorrheal endocarditis is not 
nearly so rare as is often supposed. The first point, however, is to make 
sure that we are dealing with a genuine pyuria, not with an admixture 
of urine and vaginal discharge. In the present case a specimen of urine 



AXILLARY PAIN sol 

drawn by catheter showed no pus. A smear from the vaginal discharge 
showed a variety of saprophytic organisms, but no gonococci. 

Returning now to the main complaint — the thoracic and epigastric 
pain — we notice first that it is accompanied by paresthesias, that it has 
no special relation to exertion, and is often prolonged over many hours. 
These facts, together with the negative results of physical examination, 
tend to show that it is not due to the organic type of angina pectoris, but 
belongs in the loose group of pains to which the name of "functional" 
or "false" angina has been given. As in so many other cases of this 
group, the patient's own interpretation of the pain have led to forebod- 
ings and apprehensions, and so to a concentration of attention which 
greatly increases the suffering. The clinical importance of this fact is 
that it should lead us to a much greater vehemence, directness, and cir- 
cumstantiality in our reassurances than would seem to be warranted 
by the patient's own statement. The organic effects of a fear are often 
in proportion to the patient's reticence upon the subject. 

Outcome. — After eloquent reassurance and a few days' rest with full 
diet the patient seemed so much better that she was allowed to go home. 

Diagnosis. — Artificial menopause. 

Case 151 

A Portuguese lumberman of forty entered the hospital May 30, 1908. 
His family history, past history, and habits have been good. Three 
years ago he began to have pain in the left side of the chest, with cough 
and thick yellow sputa; also a headache, backache, lack of appetite, 
occasional vomiting. For the past week he has been worse. Three 
days ago he took to bed. His throat is now rather sore. The course of 
the temperature, pulse, and respiration is seen in the accompanying 
chart l Fig. 51). 

The patient was found to be slightly delirious, with rapid res- 
piration and slight dry cough. The leukocytes were 5000 per c.mrn. 
the urine, negative. Widal reaction negative. The heart was negative. 
There were coarse rales scattered throughout both chests. Jn the left 
back, just outside the lower end of the scapula, the voice-sounds were 
slightly nasal. The right clavicle was somewhat more prominent than 
ft, and expiration just below it was somewhat prolonged. The 
abdomen was held rather rigidly, and there was slight general tender- 
there. The spleen was not felt, and there were no rose spots. 

Discussion.— A low leukocyte count in a patient who is not ap- 
parently very ill may be taken ;•> important evidence against the diag- 



3°4 



DIFFERENTIAL DIAGNOSIS 



nosis of pneumonia, especially if the patient's lungs give little evidence 
of disease. 

Pulmonary tuberculosis seems more probable in view of the long 
duration of cough with sputa, but unless we suppose that we are dealing 
with a miliary tuberculosis, there is not enough in the lungs to account 
for so sudden and severe an illness. Miliary tuberculosis cannot be ex- 
cluded. The evidence is suggestive, but not compelling. This possibil- 
ity should, therefore, be held in reserve until other alternatives are ex- 
hausted. 

Acute influenzal bronchitis, or bronchitis of some other type, might 
account for most of the facts in this case. This diagnosis also it is im- 



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possible to exclude, although my impression as I saw the patient was that 
he was too sick for simple bronchitis. The grounds of this impression, 
however, are hard to convey. Bronchitis and miliary tuberculosis, there- 
fore, remained as possibilities to be accepted or rejected as the further 
course of the case might determine. 

Influenzal infection of numerous small bronchiectases (such as occur 
very frequently with the clinical picture of chronic winter cough) is 
strongly suggested by the history and is compatible with the physical 
sign here described. It rarely causes so high a temperature, however, 
usually produces leukocytosis with profuse nummular sputa, and often 
has an emphysema associated with it. 



AXILLARY PAIX 305 

Meantime it is important not to forget the possibility of typhoid 
fever, although the time of the year is not the usual one, and although 
no definite evidence of typhoid has yet been presented. It seems to me 
essential, however, that we should consider typhoid in every febrile 
patient with vague and colorless symptoms which do not compel us to 
incriminate any one organ or group of organs. Typhoid is, beyond all 
other infections, the disease which produces fever with nothing particular 
to show for it in the way of local lesions. Hence in all such cases we 
should remember it and test for it by all the available methods. 

Outcome. — Blood-culture taken into bile was positive for typhoid 
bacilli. 

The course of the disease was uneventful. The patient went home 
well on the thirteenth of July. There was but little cough or sputa. 
The treatment consisted of J grain of calomel given every fifteen minutes 
for ten doses, at the time of entrance, followed by a suds enema; there- 
after he had alcohol and water sponges at 80 ° F. every four hours when 
the temperature was above 102. 5 F.; urotropin, 7 grains, three times a 
day twice a week, and turpentine stupes from time to time. In conva- 
lescence he had a good many boils, from one of which the staphylococcus 
was isolated. For this, staphylococcus vaccine was given. 

Diagnosis. — Typhoid. 

Case 152 

A Turkish rug- repairer of forty-seven entered the hospital May 2, 
1908, stating that when he was twenty-six he was sick for three weeks, 
and had shortness of breath on exertion. He has since been well until 
three weeks ago, when he began to have pain in the back of his neck and 
the left side of his chest, with dyspnea, orthopnea, and nocturia. For 
ten days he has had cough and yellowish sputa. 

The patient's temperature during the nine weeks of his stay in the 
hospital was generally subnormal; his pulse averaged about 100, his 
respiration 27. The daily amount of urine was generally diminished, 
averaging 25 ounces; specific gravity, 1023; no albumin or casts were 
found. 

The heart's impulse was best seen and felt in the third space, four 

inches to the left of the tnidsternaJ line; the right border one inch to the 

light of the median line. In the fourth space the impulse was barely 

felt. The sounds were loudest and the palpable impulse strongest 

clow the ensiform. The sounds were regular and of good quality, 

the pulmonic second accentuated. The pulse was of good volume and 

>n. In front the pen ussion note was dull below the left fourth rib, 
20 



3°6 



DIFFERENTIAL DIAGNOSIS 



below the fifth rib on the right, below the angle of the left scapula, while 
in the right back the dulness extended one inch higher. Over these dull 
areas breathing, vocal and tactile fremitus were diminished. There were 
many fine, crackling rales at the left base, and a few coarse crackles after 
cough at the left top, behind. The systolic blood-pressure was 145. 

The spleen was easily palpable. The abdomen and extremities 
otherwise negative. 

On the night of the fourth of May the patient's respiration became 
rapid and difficult — respiration, 42, with pulse, 130; tracheal rales could 
be heard half-way across the ward. The first heart-sound was almost 
inaudible, the second loudly accentuated. The pulse was very weak. 
The outline of the heart was normal on percussion. The patient was 
livid, cyanotic, and covered with perspiration. 

Discussion. — But for the persistently subnormal temperature coming 
on, as it has, with acute axillary pain and dyspnea, one might think of 
pneumonia in this case, although the duration is somewhat too great. 
The signs in the lungs point to fluid accumulation m both chests. 
Is this an exudate or a transudate, due to inflammation or to dropsy? 
Double pleural effusion is very rare. The absence of fever and of pain 
connected with respiration makes pleural effusion still more unlikely. 
Indeed, this possibility would scarcely have been considered but for the 
fact that there seems hardly enough in the condition of the heart or kidney 
adequately to account for so much effusion as a dropsy. 

In the urine there is really no evidence of renal disease, the slight 
variations from normal being more characteristic of passive congestion. 
In the heart, accentuation of the pulmonic second sound is the chief 
abnormality, and this is indicative less of any cardiac lesion than of a 
blocked condition of the lungs, however produced. The displacement 
of the apex impulse is also to be regarded rather as the result of the 
pleural effusion than of any disease of the heart itself. On the whole, 
therefore, there is no direct evidence of heart disease obtainable by ex- 
amination of the organ itself, and if we are to predicate any weakness of 
the heart's action, we must do so upon the evidence of passive con- 
gestion in the pulmonary circuit. This is not satisfactory, but it is 
a very familiar dilemma, and one in which experience has shown that it 
is usually safe to assume a myocardial lesion provided that there is no 
evidence of nephritis, goiter, or adherent pericardium. Such diagnoses 
as "myocarditis" used to be much more frequent than they are at the 
present day, since the habit of routine blood-pressure measurements has 
led us to recognize so many latent cases of chronic nephritis not evident 
by urinary examination. In the present case it seems inevitable that we 



AXILLARY PAIN 



307 



should blame the heart-wall for the circulatory disturbance, though it 
may be wiser to speak of "myocardial weakness" (adopting the vaguer 
functional term), rather than of "myocarditis." 

The acute attack of May 4th tends to confirm our opinion that the 
heart is organically weak. This attack will be easily recognized as one 
of acute pulmonary edema — one of the most interesting and mysterious 
of clinical pictures. The vast majority of such attacks occur in persons 
whose cardiovascular system has shown a distinct but not extreme grade 
of degeneration and weakness. In many cases the kidney has also shown 
evidence of chronic disease, but this is about the sum of our knowledge 
on the subject. As to the nature and determining cause of the attacks, 
we know almost nothing, and in a few cases we are not even warned or 
guided by any definite evidence of cardiac or renal disease; the edema 
appears, as it were, out of a clear sky. It will be understood, of course, 
that the types of edema here briefly referred to are distinguished from 
the ordinary, long-standing, gradually increasing edema of uncompen- 
sated heart disease. 

Outcome. — He was bled a pint from a vein of the left arm and given 
strychnin, -^ grain, and digitalone, 20 minims, subcutaneously. Fol- 
lowing this the pulse-rate fell at once to ico, and the perspiration and 
dyspnea diminished. The left chest was then tapped, and three pints 
of fluid removed. After this the pulse fell to 90. After J grain morphin 
subcutaneously the patient went at once to sleep and slept five hours, 
waking vastly improved, with good color, strong and regular heart 
action. 

The fluid removed from the chest had a gravity of ion, with 2.7 per 
cent, albumin. In the sediment lymphocytes made up 76 per cent., 
polynuclears, 14 per cent., endothelial cells, 10 per cent. 

Two nights after this he again became uncomfortable; the other 
chest was aspirated and four pints of fluid withdrawn. The specific 
gravity was again ion; the albumin only 1.2 per cent.; lymphocytes, 
77 per cent. The patient was then given magnesium sulphate ] ounce 
every morning, a dram of French Vermouth in a small amount of water 
just before dinner and supper, diuretin, 15 grains four times a day. 
Following the tapping of the chest the amount of urine increased markedly. 
On the sixth of July he left the hospital much relieved. 

Diagnosis. — Weak heart; acute pulmonary edema. 

Case 153 

A single "man of twenty-five, a nurse, entered the ward on January 
2, 1906. The night before she had had .some pain in the left Bide. She 



3 o8 



DIFFERENTIAL DIAGNOSIS 



was awakened by it several times in the night. She finds it uncomfortable 
to lie on the right side or on the back, but pressure on the left side, or 
lying on that side, relieves the pain. She has an extremely tender spot 
under the right border of the ribs in front. 

Examination showed spasm in the right hypochondrium, with tender- 
ness. The pain, however, was consistently referred across the abdomen to 
a point in the left axilla on a level with the left nipple. Physical examina- 
tion, including blood and urine, was otherwise negative. The temperature 
ranged between 99 ° and 101 F. The pain did not 
seem to be affected by morphin, and came on two or 
three times a day in spasms lasting one-quarter to 
one-half hour. The tender point in the right upper 
quadrant grew steadily more rigid and more sensitive. 
Pressure there caused pain to shoot to the left axilla. 
She was seen daily by a surgical consultant, who did 
not advise operation. On the fourth day the white 
cells rose to 14,000. 

Discussion. — This case is introduced to exemplify 
an unusual reference of pain to a point far removed 
from the lesion producing it. The tenderness and 
spasm turn out here, as in so many other cases, to 
guide us better than the pain, when the two diverge. 
A rhythmic or spasmodic character in any painful 
seizure usually turns out to mean frustrated peristalsis 
within a hollow muscular organ. But there is no such 
organ in the left axilla; the nearest hollow muscular 
organ is the heart, and there is nothing else in the 
clinical picture to connect the pain with that organ. 
The rising leukocyte count and the fever are data not ordinarily 
associated with angina of any type. 

Outcome. — Three days later the abdomen was opened and a much 
distended and twisted gall-bladder found; the cystic duct was dilated, 
twisted, and occluded by a large stone. Three other stones were also 
found in the gall-bladder, which was acutely inflamed. 
Diagnosis. — Gall-stones. 



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of case 153. 



Case 154 

A Swedish machinist aged twenty-five entered the ward February 8, 
1907. Five weeks previously he had suffered from tonsillitis. In two 
weeks he was back at work, but began to have pains in his legs and feet; 
at one time both knees were red and swollen. Ten days ago he gave 



AXILLARY PAIN 309 

up work and went to bed, with fever, headache, loss of appetite, and 
weakness. His chief complaint for the past week has been pain in both 
chests, worse in the right front. His legs have shown only indefinite 
stiffness and soreness in the past few days. 

Physical examination of the chest showed in the right axilla very 
slight dulness, with diminished breath-sounds and a suggestion of friction. 
The heart was negative. There was no redness or swelling of any joint, 
but some pain on motion of the right knee, and a slight rigidity of the 
neck. Belly negative. Temperature, 101.8 F.; pulse, 120; respiration, 
30; hemoglobin, 70 per cent.; white cells, 24,000; urine normal. 

On the twelfth of February there was still no evidence of any localiza- 
tion of the infection except that the signs in the lower right axilla had 
slightly increased. The patient looked decidedly sick, and the white 
count had risen to 25,400. On the fourteenth, pain and edema of the 
whole right leg appeared without tenderness; the next day swelling ap- 
peared in the left foot and the veins below the left knee were distended; 
there were still no tenderness and no change in the signs in the right chest. 
By the sixteenth the swelling of the left leg had considerably increased, 
and there was tenderness over the red, cord-like veins of the left calf. 
The white count remained the same, 88 per cent, of the cells being poly- 
nuclear. 

The patient remained in the hospital until August 12th — six months. 
There was some sloughing of the superficial tissues of the right foot. 
A well-marked nephritis appeared on the twenty-fourth of February, and 
lasted until July, but finally disappeared altogether. Pleurisy appeared 
in the left side on the tenth of May, but disappeared in the course of a 
week. Thrombosis appeared in both arms in the early part of March, 
and in the middle of the month there was bloody expectoration for a couple 
of days, without any special pulmonary signs to account for it. By 
April 1 st the arms were normal and the left leg nearly so. 

A marked anemia gradually developed, so that on the thirteenth of 
April the red cells were 2,725,000, with 65 per cent, of hemoglobin. 
Late in June there were purpuric spots on the dorsum of the left foot, 
but they disappeared within a few days. 

Discussion. — As the history of this case opens with a tonsillitis, 
it may be well to consider some of the lesions which the clinical experience 
of the last fifteen years tends to associate with tonsillar inflammation. 
Although the majority of cases of tonsillitis progress beyond their origin 
no further than the lymphatic glands at the angle of the jaw, the very 
striking prostration which accompanies and follows the acute infection 
probablv indicates that the disease rarely remains local. It seems to be 



3io 



DIFFERENTIAL DIAGNOSIS 



shown beyond reasonable doubt that in many cases an infection first de- 
monstrable in the tonsil appears soon after in one or another synovial 
membrane or joint surface, in the endocardium, in the kidney, or on 
some serous surfaces. This may be taken to indicate that bacteria are 
circulating in the blood-stream in a considerable proportion of cases, 
though they have not often been isolated by blood culture. 

The case above described is remarkable chiefly because it narrates the 
fortunes of a patient who suffered, one after another, most of the common 
complications of tonsillitis above referred to. Beginning with multiple 
arthritis and right-sided pleurisy, he next suffered a series of infections 
of the peripheral veins, leading to multiple thrombi. Then came the 
nephritis, which I have often seen occurring in tonsillitis as the only mani- 
festation of the body's effort to expel invaders. The pulmonary bleeding 
is probably to be explained as analogous to the purpuric spots which 
appeared for a few days in the latter part of his illness. Only histologic 
examination could decide whether these pulmonary and cutaneous hem- 
orrhages were due to embolism or to some other cause. The develop- 
ment of a marked anemia in a six months' illness of this severity is not to 
be wondered at, since chronic sepsis always tends to produce anemia. 
But it is quite remarkable that the heart escaped, apparently without 
injury. Possibly the transient rigidity of the neck might be interpreted 
as a larval infection of the meninges ("meningismus"), since we know 
that all the serous membranes — pleura, pericardium, peritoneum, men- 
inges — may be attacked in cases of generalized sepsis. 
! Another very remarkable feature about this case was that the patient's 
final recovery was complete. The treatment consisted essentially of 
good nursing. 

Diagnosis. — Sepsis with thrombi. 

Case 155 

An Italian laborer of twenty-nine entered the hospital on March 18, 
1908. The family history was negative; his past history likewise so; his 
habits good. 

Four weeks ago he began to have pain in his left chest, chiefly low 
down in the axilla, accompanied and aggravated by cough or deep 
breathing. There was slight dyspnea on exertion. For three days he has 
felt chilly and feverish, especially at night. He has noticed nothing 
remarkable about his urine, and no pain except as above described. 

On physical examination the heart showed nothing abnormal. The 
right side of the chest moved better than the left, and there was slight dul- 
ness at the right pulmonary apex as low as the second rib, with broncho- 



AXILLARY PAIN 



311 



vesicular respiration and increased voice. At the base of the left axilla 
the percussion-note was flat below the sixth rib. Tactile fremitus was 
absent, voice- and breath-sounds diminished. Over the area of flat- 
ness were scattered a few fine rales, and some were audible as high as the 
second rib. In the back the area of flatness reached up to the lower angle 
of the scapula. Tactile fremitus was diminished over the whole left 
back, and absent, together with voice- and breath-sounds, below the angle 
of the scapula. A paravertebral triangle was percussed out on the op- 
posite side. The abdomen showed considerable general rigidity and 
in the extreme flanks some dulness, which did not, however, exhibit any 
change with change of position. During the next ten days his tempera- 
ture ranged between 99 and 101 F., his pulse between 70 and 80, his 
respiration between 20 and 25, his urine between 40 and 50 ounces in 
twenty-four hours, with a slight trace of albumin, a moderate amount of 
pus, many hyaline and granular casts, some of which have blood or fat 
adherent. The leukocytes were 6700; hemoglobin, 75 per cent. 

By March 2 2d the dulness in the chest had somewhat diminished, 
and the paravertebral triangle was not evident. The dulness on the 
left side seemed to rise higher in the axilla than near the spinal 
column. A large mass was now felt in the left flank, but could not be 
definitely outlined on account of the rigidity of the whole abdomen, which 
did not relax even in a warm bath. 

On the twenty-fourth of March the x-ray showed apparently a large 
stone in the left kidney. 

On March 27th the area of dulness in the left chest had not changed, 
but there were coarse, moist rales in the right lower back and axilla. 
The urine still showed a slight amount of pus. Cystoscopy showed this 
pus to issue from the left ureter, while normal urine came from the right. 

Discussion. — The signs at the base of the left axilla and in the back 
seem to indicate a localized pleurisy, with or without a small effusion. In 
view of the later developments of the case, however, I believe that the para- 
vertebral triangle was percussed out largely as the result of "expectant 
attention" — i. e., of the interne's conscientious determination to find it. 
Even at the beginning of the case every one who saw the patient felt that 
the pleural effusion was not sufficient to account for the marked fevei 
and constitutional symptoms. Weal! thought there must be "something 

. of it." 

Our first clue to that "something" in the background was the find- 
: pus in the urine. This led us to search more carefully tin- region 

of the kidneys, whence the mass in the left flank came to light. As I 
read the record now it i^ amusing to note how promptly the chest signs 



312 DIFFERENTIAL DIAGNOSIS 

retire into the background of the clinical picture as the kidney begins to 
loom up in the foreground. How far this represents the actual course of 
events in the patient and how far it is a matter of the historian's psy- 
chology it is now difficult to say. 

Outcome. — On March 28th operation showed a large kidney filled 
with thick pus and adherent to the diaphragm and other structures. 
No stone was found, but there was a calcareous plate near the surface of 
the kidney; no histologic report is preserved. 

The patient made a good recovery. 

Diagnosis. — Pus kidney (tuberculous ?). 

Case 156 

A widow of forty entered the hospital February 13, 1908. She had 
typhoid fever three years before, and was operated on for extra-uterine 
pregnancy seven years before. Otherwise she has never been sick, but 
has had many colds this winter. Six weeks ago she began to suffer 
from pain in the left side of the chest. Four weeks ago she had to give 
up her work on account of vomiting immediately after eating. The 
vomitus rarely contained food. It usually was greenish. There was 
constant soreness in the epigastrium, and a good deal of pain in the left 
arm and left side of the chest. She has taken almost no solid food for sev- 
eral weeks. She has considerable dyspnea and palpitation, and has lost 
twenty-six pounds. Twice she has had shivering spells lasting several 
hours at night. She admitted the occasional use of alcohol, and it was 
apparent on her breath at the time of entrance. Some nights she passes 
urine at frequent intervals. 

Physical examination was negative except for considerable tenderness 
in the epigastrium and moderate enlargement of the axillary glands on 
both sides. Blood-pressure, 135. 

Discussion. — On p. 738 of this book I have referred to a case 
diagnosed and treated as neurasthenia, but dying shortly afterward of 
cancer of the pleura. The symptoms in that case were not unlike those 
described above, and my remembrance of the former mistake leads me 
to be especially cautious in the diagnosis of supposedly neurasthenic 
pains in the side of the chest. The presence of enlarged glands would 
be quite consistent with malignant disease of the chest, and is often one 
of the most important clues to the discovery of that trouble. The import- 
ance of this enlargement, however, is weakened by the fact that it is bi- 
lateral. Adenitis secondary to malignant disease is usually unilateral. 
In the present case I did my best to find signs of malignant disease 
by physical examination of the chest, but could find nothing. 



AXILLAKY PAIN 



313 



By the Qegative results of physical examination, which included a 
temperature record, we were able also to exclude pleurisy. 

The extension of the pain to the left arm, the presence of dyspnea 

and palpitation, and the age of the patient are data quite consistent with 
the diagnosis of angina pectoris. Against this, however, is the al 
of any relation to exertion as a cause of pain, the longstanding and 
moderate character of the suffering, and the low blood pressure. 

After the exclusion of these and all the other possibilities which we 
could call to mind, it seemed best to make a diagnosis of neurosis and use 
that as a working basis for a therapeutic test. 

I interpret the left axillary pain as due to that commonest of all 
causes for such a complaint, viz., flatulence. When the stomach is over- 
distended, whether by atmospheric air which has been swallowed and 
"cribbed" or by the products of gastric fermentation, the u Ma%en- 
hUut" or bubble, which is usually to be seen near the cardia by fluoros- 
copy, swells to huge dimensions, invades the axillary region, and often 
causes much discomfort. The patient usually thinks she has heart dis- 
ease; the thought increases her nervousness and thus her flatulence. 
The vicious circle is then in complete working order. 

Outcome. — The patient was put to bed and given a diet of liquids 
and soft solids, with paraldehyd, half to one teaspoonful, on two success- 
ive nights. Within two days the vomiting had ceased and she felt much 
better. She had apparently been working hard, and was of a neurotic 
type, easily frightened by the slightest unexpected noise or occurrence. 
She was well enough to go to work again on the twentieth of February. 

Diagnosis. — Neurosis. 

Case 157 

A Greek waiter of twenty-one, with a negative family history, entered 
the hospital November 13, 1907, with the statement that he has been 
feeling rather poorly for the past four months, but had no definite symp- 
toms until three weeks ago, when he began to have frequent severe pains 
in the front and left side of his chest and a distressing cough without ex- 
ration. The pain and cough were both worse at night, but he has 
Ixren very comfortable lying flat, and has complained of no shorti.' 
breath. He has been chilly and feverish and had much vertigo and 
frontal headache. During the past three weeks he has lost 20 pounds. 

At entrance the patient was unable to lie down on account of dyspnea. 
The cardiac apex was neither visible nor palpable* The area of cardiac 
dulness, as shown in the diagram, had a total width of 11 I inch 
left border of dulni - to the left of the midsternum in the 



3*4 



DIFFERENTIAL DIAGNOSIS 



fifth interspace. In the upper front of the right chest there was tubular 
breathing over the dull area, and in the left back, near the angle of the 
scapula, all the signs of solidification were present. The abdomen was 
everywhere dull except in the umbilical region and in the left flank. The 
patient's temperature was irregularly elevated for the whole of his three 
months* stay in the hospital. (See Fig. 53.) 

The blood showed 9900 white cells and 90 per cent, hemoglobin. 
The urine was not remarkable. A paradoxic pulse was demonstrated 
on the fifteenth. 

Discussion. — If we accept as accurate the record of a to-and-fro 
friction-sound at the point shown in the diagram, there seems no reason 
for doubt that pericarditis is present. It remains to discover, if we can, 
whether a pericardial effusion is present and by what other lesions the 
pericarditis is complicated. 



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The diagnosis between a pericardial effusion and a dilated heart is 
notoriously difficult, often impossible. In the present case we have no 
good cause for such a dilatation of the heart — no valvular or arterial lesion, 
no goiter or chronic nephritis, no history of beer-drinking. The area 
of solidification in the left back is, in all probability, due to pressure ex- 
erted upon the lung either by a pericardial effusion, a pleural dropsy, 
or a greatly dilated heart. The latter possibility is very rarely mentioned 
in text-books, but I have been convinced by postmortem evidence that 
a heavy, distended heart in a patient who lies persistently on the back may 
compress the left lung so as to produce an atelectasis or pseudopneumonic 
condensation of the lung similar to that often caused by pericardial 
effusion. A common mistake in these cases is to suppose that a lobar 
pneumonia is present. Experience has shown that when we hear the signs 



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Fig. 54. — Lateral limits of an area of percussion dulness found in Case 157 



AXILLARY PAIN 



315 



of solidiiication near the angle of the left scapula in the course of a case 
showing a greatly dilated heart, with or without pericardial effusion, 
these signs turn out in the great majority of cases to be due to pressure 
exerted on the lung by the heart, or by a pericardial or pleural effusion, 
and not to an exudate in the lung. 

The presence of a high continued fever and the absence of any cause 
for cardiac dilatation in the present case incline me to believe that 
there is a pericardial effusion. The long duration of the case with- 
out any notable improvement suggests that the pericarditis may be 
tuberculous. 

The extensive dulness in the abdomen is in all probability due to fluid 
which may be the result either of tuberculous peritonitis or of stasis. 
Ascites is especially apt to accumulate as the result of a chronic pericardi- 
tis which has gone on to complete obliteration of the pericardial sac, but 
it does not seem probable that the inflammation has lasted long enough in 
this case to bring about that result. Further evidence as to the nature of 
the fluid in the peritoneum might be obtained by tapping, for a dropsical 
fluid would probably be of lower gravity than one due to tuberculous 
peritonitis. 

Outcome. — He was admitted to Tewksbury Almshouse January 22, 
1908. 

The left lung continued to show the flatness and loss of voice-sounds 
below the fourth rib in the axillary line. Sputum was examined twelve 
times and found negative for the tubercle bacillus. Slight dulness and 
bronchial breathing spread to both lungs. 

In February his temperature rose daily, going as high as 103 ° and 
104 F., but usually reaching 102 ° F. 

He died June 4, 1908. No autopsy. 

Diagnosis. — Pericarditis. 

Case 153 

A night watchman of forty- six entered the hospital August 24, 1906. 
Be has been a hard drinker up to eleven months ago. He had syphilis 
twenty years ago. For over two years he has been troubled by a hack- 
ough without sputa, accompanied by night-sweats and a slight pain 
in the left side of the chest. He has gradually increasing dyspnea on 
exertion, but can still lie flat and with the greatest comfort on the right 

For the past ten months he has been having pain in the left upper 
■ and paroxysms of distressing cough. At times he loses his voice 
for a few hours, bul is never constantly hoarse. Nitroglycerin has 

him considerable relief, but he has rattled and wheezed all summer, 



31 6 DIFFERENTIAL DIAGNOSIS 

especially during the last four days. He sleeps poorly, has lost much 
weight, and has no appetite. 

The heart's apex is in the fifth space, one-half inch outside the nipple, 
the right border of dulness two inches to the right sternal margin in the 
fourth space. There is marked bulging of the left chest over the area 
shown in the accompanying diagram, and considerable pulsation in the 
third and fourth left spaces. The veins of the neck and arms are dis- 
tended. Loud groaning, whistling sounds are audible throughout both 
lungs. Physical examination of the heart, blood, and urine is otherwise 
negative (Fig. 55). 

Discussion. — If a careful physical examination were made and duly 
meditated on in this case, the only hesitation in diagnosis would be on 
the question whether aneurysm or malignant disease of the chest is the 
cause of the patient's sufferings. In the absence of such an examina- 
tion, however, I have known a case very similar to this to be treated 
as consumption for a number of months, the cough, night-sweats, emacia- 
tion, and pain in the chest being accepted as sufficient evidence of 
phthisis. 

In another case the wheezing and rattling led straight to a diagnosis 
of bronchial asthma and to all sorts of therapeutic attempts based on 
that diagnosis. 

Returning to the only diagnostic problem which ought to exist in this 
case (aneurysm or malignant disease of the chest), I may say in the first 
place that in a considerable number of cases in which I have known this 
discussion to arise, the outcome has always shown aneurysm. In this 
man the history of syphilis, the absence of any glandular enlargement, and 
the slow march of the symptoms, which apparently have lasted two years, 
all favor aneurysm. The loss of weight is perfectly characteristic of 
aneurysm, and occurs, as I have previously shown, 1 in the vast majority 
of all cases. I emphasize this point because in the discussion of this 
differential diagnosis I have several times heard emaciation adduced as 
evidence against aneurysm and in favor of malignant disease. 

Outcome. — X-ray showed a large shadow corresponding to the area 
of dulness. The mass seemed to grow and then to decrease in size in the 
next few days, the pulsation varying much from time to time in amount 
and in extent. There were two main projecting points — one over the pre- 
cordia, and one above it, under the clavicle. Sarcoma of the chest-wall 
was considered seriously. The patient died on the sixteenth. Autopsy 
showed aneurysm of the first portion of the aorta; rupture into the 

1 Two Possible Causes of Emaciation Not Generally Recognized, R. C. Cabot, M. D., 
Jour. Amer. Med. Assoc, March 17, 1906. 




lig. 55.- Physical signs found in a patient who complained of dyspnea, cough, emacia- 
tion, night-sweats, and pain in the chest. 



AXILLARY PAIN 317 

pericardium; compression atrophy and bronchopneumonia of the left 
lung. The aneurysm was filled by a very thick clot lying in front of and 
above the heart. 

Diagnosis. — Thoracic aneurysm. 

Case 159 

In March, 1898, a housewife of thirty-three came to the hospital for 
hemoptysis, supposedly due to phthisis. No sign was found in the lungs. 
In ( )ctober, 1898, she was again treated for pleurisy with effusion and 
fistula in ano. She had had a nervous breakdown in 1896, and had been 
very irritable and self-centered since that time. 

In April, 1899, she began to suffer from pain in the right side of the 
chest, much aggravated by coughing and laughing. 

The urine contained a trace of bile and a good many leukocytes; other- 
wise it was negative, as were the blood, temperature, pulse, and respiration. 

Physical examination, April 23d, was negative save for a patch at the 
right base near the scapular angle, where there were slight dulness, dim- 
inished voice, respiration, and fremitus. 

Discussion. — Pulmonary hemorrhage of any amount — an ounce or 
more — means pulmonary tuberculosis in 999 cases out of ioco, if disease 
of the heart and aorta be excluded, as they easily can be in most cases. 
The other traditional causes of hemoptysis — disease of the throat, 
vicarious menstruation, hemorrhagic conditions — amount practically 
to nothing; that is, they are usually quite obvious, like purpura haemor- 
rhagica, or quite mythical, like vicarious menstruation. Pulmonary 
hemorrhage due to distomiasis never occurs in North America except 
among Japanese immigrants. 

The fact that signs are absent on examination of the lungs after 
a hemoptysis due to tuberculosis is entirely according to rule when 
hemoptysis is the first evidence of disease. We almost never find any 
Signs of disease until some months later; in many cases we never find 
them at all, and only the postmortem examination proves tuberculosis. 

All this, however, refers to an event over a year old. Is it not possible: 
that her suffering, at the present time, is connected with her nervous 
condition and due to habit pain? Against this hypothesis we have the 
fact that she has previously had pleurisy with effusion and fistula in ano, 
both of them tuberculous affections in practically every cast-. Hearing 
troubles in mind, we naturally assume that her present pain is in 
■Ome way produced by her old pleurisy, of which there seems to be Still 
some evidence at the right base. There arc, however, two other possibil 
h mu»t first be considered brieflv: 



318 DIFFERENTIAL DIAGNOSIS 

The urine contains bile. This directs our attention to the liver; but 
enlargement of the liver upward may produce in the right back all the 
signs here described — signs which, if interpreted as pleurisy, might be 
due either to a small effusion or to marked pleural thickening. I have 
known abscess of the liver to produce exactly these signs, so that it was 
mistaken for empyema. Against the possibility of liver disease there is 
not a great deal to be said, as our methods for detecting liver disease are 
so few and unsatisfactory. We may note, however, that there seems to 
be no enlargement of the liver downward, no bile staining of the skin 
or conjunctiva, none of the ordinary causes for cirrhosis, hepatic abscess, 
passive congestion, amyloid or fatty metamorphosis, no change in the 
spleen, glands, or blood to suggest leukemia or Hodgkin's disease. 
This is the best that we can do to exclude liver disease. Had these same 
signs appeared in the back following an appendicitis, amebic dysentery, 
or cholelithiasis, the situation would suggest hepatic abscess. 

I once made a diagnosis of purulent pleural effusion in a case bearing 
a good deal of resemblance to this one. I put in a needle an inch and a 
half below the angle of the scapula, drew pus, and promptly handed over 
the case to a surgeon for drainage. He opened the pleura, found it 
smooth and clean, and indulged in disparaging remarks on medical diag- 
nosis. Further exploration, however, showed that the diaphragm was 
pushed up nearly to the angle of the scapula, and that through its domed 
surface fluctuation could be detected. A second puncture, ten days later, 
after the pleura had healed without infection, liberated a quart of pus 
from the region of the kidney. Since that time I have always remem- 
bered the possibility of perinephritic or subdiaphragmatic abscess when 
dealing with what appears at first sight to be an effusion (serous or puru- 
lent) at the right base. The presence of leukocytes in the urine makes 
it all the more necessary to consider the kidney in this case, but we must 
first make sure that those leukocytes come from the urinary tract by 
obtaining a catheter specimen of urine. When this was done, the urinary 
sediment no longer showed leukocytes, and as there were no other facts 
pointing distinctly to the kidney, I returned to my original idea — 
pleurisy at the right base. 

This case is one of many which exemplify the long duration of pain 
and of physical signs after the healing of a pleural effusion. Perhaps 
in the majority of cases there is more or less suffering for a year. 

Outcome. — The pain remained mostly in the back, and not in the 
side, during the five days of her stay in the hospital, but soon disappeared 
with rest, full diet, and counterirritation. 

Diagnosis. — Old pleurisy. 




AXILLARY PAIN . 319 

Case 160 

A typewriter of twenty-three lost her mother and one brother of 
phthisis. Two and a half years ago she was in bed several weeks on 
account of pain in the left axilla. The whole attack lasted three months. 

Lately she has noticed pain in the left side when she is nervous — 
sharp for a few minutes, and leaving an ache for two or three days after- 
ward. Sometimes exertion relieves it. Coughing or sneezing does net 
increase it. 

Five months ago the pain increased. For six weeks she slept almost 
none and walked the floor much. Her weight fell from 132 to 108. 
The pain is chiefly in the left side, but there is also a constant sense 
of pressure in the right breast and back, with occasional sharp pains. 
Suffering is worse at night. She has a good deal of indigestion and con- 
stipation. 

Examination. — Cardiac apex in fifth space, nipple-line. Accom- 
panying the first sound is a systolic murmur, loudest at the apex, but 
audible also over the whole precordia and in the left axilla. The pul- 
monic second sound is slightlv louder than the aortic. 

Tender spots near the left lower scapular edge, in post-axillary line, 
in the axillary line in fifth, sixth, seventh spaces, and along sternal border 
[fourth to eighth ribs] were found. Sensation normal. 

Discussion. — In view of the site of the pain and the family history 
of tuberculosis, it would be wrong not to consider pleurisy in this case; 
but there was no definite evidence of it on physical examination, and 
without such evidence the diagnosis can never be made. 

Pain due to dyspepsia and flatulence would hardly be so constant, 
and this same characteristic excludes both types of angina pectoris. 
Muscular pains (pleurodynia) would show exacerbation rather than 
relief by exertion. Of local diseases of the chest-wall we have also no 
evidence. 

Intercostal neuralgia is characterized by pain like that here described, 
and especially by tender points corresponding approximately with those 
which physical examination has revealed. I believe intercostal neuralgia 
to be a rare disease, although the diagnosis of it is so common. By 
intercostal neuralgia one means ordinarily the so-called " primary " type, 
unrelated to any cause of pressure, such as aneurysm or spondylitis, 
ire pains of this type arc, of course, by HO means uncommon, 
but primary intercostal neuralgia unaccompanied by herpes and without 
any known cause is. I believe, distinctly rare. The diagnosis, like 
all di if a '' primary " or obscure lesion, is one with which we are 






320 DIFFERENTIAL DIAGNOSIS 

never quite content, and which we can tolerate only when we have done 
our best, by rigid scrutiny and thorough sifting of all other recognized 
possibilities, to find a cause. In the present case, for example, I should 
not be satisfied unless disease of the spinal column had been, so far as 
possible, excluded. 

Outcome. — The pain gradually disappeared in six weeks. Many 
forms of treatment were tried, but none of them had any effect that I 
could discover. 

D i agno si s . — Intercostal neuralgia . 

Case 161 

An alcoholic Irish teamster of twenty-eight has noticed for a week a 
pain in his right lower axilla. The pain has several times been associated 
with vomiting and a slight cough. No injury is remembered. 

Family and past history good. 

Physical examination is negative, save for a rounded swelling about 
15 cm. in diameter near the right costal margin in the axilla. The 
swelling is brawny, with a slightly fluctuant crater in the center. 

Discussion. — There seems every reason to believe that the pain and 
the tumor are connected in this case. It remains to ask, What is the nature 
of the tumor? 

The commonest causes are: septic osteomyelitis or tuberculous osteo- 
myelitis of a rib. The patient might have broken one or more ribs with- 
out knowing it during one of his drinking bouts, but the resulting cal- 
luses would not produce a mass like that here described. 

A fatty tumor or an empyema necessitatis would not have a brawny 
surface. Either of these lesions, if fluctuant, would be fluctuant through- 
out. Malignant disease of the chest- wall does not often show itself 
at this point. Actinomycosis cannot be excluded ; it is, however, a rare 
lesion, and the commoner causes of a swelling at this point should be con- 
sidered first. 

Further diagnosis is impossible without incision. 

Outcome. — Two ounces of pus were removed by incision and a sinus 
found leading to a rib. Rough bare bone was found at the bottom of 
the sinus. There was no evidence of actinomyces. The patient seemed 
greatly debilitated. 

Diagnosis. — Costal tuberculosis. 

Case 162 

An unoccupied girl of twenty-eight entered the hospital January 15, 
1908. Nine months before she caught cold at a dance, and a week after 



AXILLARY PAIN 



321 



began to have pain in the left chest. Ever since it has been a constant 
ache, at times becoming severe, worse after eating; it is not affected 
by respiration or motion. Her appetite is good, but she has complained 
of a great deal of " gas upon her stomach," and for some months has lived 
upon a diet excluding meat and eggs, sweets, salt, and fried stuff. She 
never vomits. Her bowels are constipated, and she has considerable 
dyspnea on exertion. One year ago she weighed 150 pounds; she thinks 
she has lost weight since. 

Physical examination shows a rather obese girl weighing 149 \ pounds. 
There is a harsh systolic murmur audible all over the precordia, but 
not transmitted elsewhere. The apex is neither visible nor palpable. 
The left border of dulness is in the nipple-line and fifth space. The 
aortic second sound is louder than the pulmonic second sound. Physical 
examination, including blood and urine, is otherwise normal. 

Discussion. — The only objective abnormality in the physical exam- 
ination is the cardiac murmur and the accentuation of the aortic second 
sound. These items are not sufficient, separately or in combination, 
to warrant any inference of disease. The history shows that she has been 
starving herself, yet on physical examination she is obese. Possibly 
she is trying to reduce her weight, which may have been greater six 
months ago. 

In the absence of any local cause for the pain one naturally thinks 
of neuralgia, especially since the diet is so insufficient. But there are no 
tender points corresponding to the nerve exits, while the fact that pain 
is worse after eating is very uncharacteristic of neuralgia. While this 
diagnosis cannot be positively excluded, it seems rather unlikely. 

Muscular pain (pleurodynia) should be more distinctly related to ex- 
ertion and less to food. 

In view of these facts and of the absence of any apparent connection 
between the cardiac murmur and the pain, it seems reasonable to believe 
that it is due to a digestive disturbance favored by insufficient food 
and associated with gaseous distention. On p. 288 I have already men- 
tioned the great frequency of axillary pain due to this cause. Such pain 
is very common as an element in the clinical picture of the gastric neuroses, 
with or without starvation. 

No cause of Stomach trouble in women is commoner than Starvation. 
The vicious circle is established in the following manner: Some tempo- 
ran- fatigue or depression of vitality results in digestive disturbance. 

The food eaten last or most abundantly is blamed by the patient and 

ded from the subsequenl meals. Digestive disturbance continues. 
foods are excluded. The nutrition of the whole body, including 



21 



3 22 



DIFFERENTIAL DIAGNOSIS 



that of the stomach itself, begins to suffer, and digestion is still further 
delayed by gastric stasis or insufficient secretion. The suffering thus 
produced makes the patient aspirate air into the stomach ["cribbing"], 
which in time increases the discomfort and renders her still more timid 
about eating. The circle is then complete. To break it one must force 
the patient to eat, despite considerable pain, until some gain can be made 
in the general and so in the local nutrition. A weakened stomach, like 
a weakened muscle, cannot be strengthened without exercise, and this 
entails, for a time, increase of suffering. 

Outcome. — The patient was given a full diet, a tight swathe, J 
dram bicarbonate of soda after meals, and half a dram of the elixir of the 
valerianate of ammonia before meals. 

By January 21st she seemed perfectly well and able to go home. 

Diagnosis. — Starvation. 



AXILLARY PAIN 



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CHAPTER XI 
PAIN IN THE ARMS 

Case 163 

A theatrical advance agent of thirty-five entered the hospital January 
10, 1907. Ten days ago he strained his arm while swinging on a trapeze. 
A week ago he was suddenly taken with aching and soreness in the 
muscles of the right arm, with a slighter amount of pain in the other arm 
and in the legs. The joints were not affected, and there was no fever or 
chill, but the right arm was somewhat swollen above the elbow, where it 
was more tender than in any other part. He had severe, constant, frontal 
headache and a harassing, dry cough. He stayed in bed for the first 
day, but, feeling no better, got up again and has been up most of the time 
ever since. Four days ago he began to be short of breath, especially on 
exertion, and for three days he has had chilly sensations. To-day he 
complains chiefly of dyspnea, cough, soreness all over his body, head- 
ache, weakness, and a sharp pain in his right wrist on motion. He 
gets up three or four times at night to pass his water. 

On physical examination, temperature, pulse, respiration, blood, and 
urine were found to be normal. The patient looked sick and breathed 
with some difficulty. The lungs were slightly dull in both backs, and 
showed many fine and coarse rales with a few squeaks on both sides. 
The heart was negative, likewise the abdomen. The rales in the chest 
disappeared the next day. The principal complaint thereafter was of 
pain in the whole right arm, and in it there were slight general swelling and 
apparently great tenderness. The arm was held rigid most of the time. 
Dr. Goldthwait found nothing abnormal about the bursae or joints. 

The pain did not prevent sleep at all, and the temperature remained 
normal. 

On the eighteenth of January the patient dropped and broke a cup. 
Immediately after this he had a convulsion, in which his body became 
rigid and his eyes rolled up, while the lids flickered. 

Discussion. — All that physical examination reveals in this case is the 
evidence of a slight bronchitis and a tender arm, very possibly due to a 
strain. There is no evidence of inflammation or of any lesion of bone or 
324 



Causes of Brachial Pain 



VARIOUS TYPES OF ARTHRITIS (INFECTIOUS, ATROPHIC, HYPERTROPHIC) 

SUBACROMIAL AND] 

S U B C O R A C O I D - ^HMHHH^MHHHIHMM^^BH 203 
BURSITIS ) 



FATIGUE AND OC-O 
CUPATION NEU- [ 
ROSIS > 



NEOPLASM OF 
THE ARM A 
SHOULDER 



ND V 



91 



OSTEOMYELITIS | ^^ 20 
HUMERI i 

ANEURYSM Mi 14 

NEURALGIA CAUSE?) MM 10 

MEDIASTINALTUMOR ■ 7 



CERVICAL RIB I 3 

ANGINA PECTORIS I 1 

Among the other causes not here represented are : 

(a) Wounds, with or without lymphangitis or thrombosis : 

(b) Bruises, fractures, sprains, and strains ; 

(c) Poliomyelitis and cortical irritation (tumor, gumma). 



826 



PAIN IN THE ARMS 



3 2 7 



joint. The pain does not follow the course of any nerve, is independent 
of exertion, and associated with no evidence of cardiac or vascular disease. 
Cervical rib, aneurysm, and tumor were excluded by careful examination. 

In view of all this negative evidence, and in consideration of certain 
neurotic mannerisms which were obvious, but not easily described, we 
were strongly inclined from the outset of the case toward the diagnosis of 
traumatic neurosis. After the fit, which was clearly hysteric in nature, 
we felt much surer of our previous diagnosis, and instituted treatment 
based upon it. 

Outcome. — From the fit above described he could not at once be 
aroused. He was, therefore, ignored, and after about twenty minutes he 
sat up and acted as if nothing had happened. Up to this time the arm 
had been held rigidly, and all attempts to move it had been resisted — 
as he said, because of severe pain. After the convulsion he was given a 
severe scolding, and the arm was raised and the fingers were bent and 
straightened again by force for about five minutes, in spite of his shrieks 
and protestations. Motions not anticipated by the patient were found 
to be free. The next day the patient was up and about the ward, the 
use of his arm as good as ever, and there was no sign of his previous 
incapacity. He is now anxious to go out and get to work. The chest is 
clear, and he was discharged well. 

It is worth noting in this case that there was no suit for damages in 
contemplation. Some writers on traumatic neurosis and many lawyers 
engaged in defending suits for damages try to persuade us that the ex- 
pectation of a money payment as the result of litigation produces most 
of the symptoms of the traumatic neuroses. Cases like that here de- 
scribed upset such assertions. 

Diagnosis. — Traumatic neurosis. 

Case 164 

A Turkish jeweler forty-five years old entered the hospital December 
26, 1907. His family history and past history were not remarkable. 
He denied venereal disease. Three years ago he had his first attack of 
"rheumatism " in the right hand and forearm, later in the other hand and 
other arm. There was no involvement of the joints and no increase of 
pain by motion. Six months later the pain extended up to the shoulders 
and to the neck. For this rheumatism lit- has been treated by many doc- 
tors, but without relief. Three years ago he gave up work and has never 
resumed it. Fifteen months ago he began to have a distressing cough 
with foamy sputum and this has continued ever since. For about the 
same period he has noticed hoarseness and dyspnea on exertion. I'm 



328 DIFFERENTIAL DIAGNOSIS 

the past five months he has been unable to lie down at night. His appe- 
tite remains excellent, but he sleeps poorly. 

A loud ringing cough is the patient's most striking symptom, and no 
cause for this could be found on examination of the lungs. Over the 
base of the heart a loud, harsh systolic murmur is heard. There is an 
area of percussion dulness as shown in the diagram (Fig. 56) . Physical 
examination is otherwise negative. 

Discussion. — In view of the symptoms which have recently developed 
in this case it no longer presents any diagnostic problems of special 
difficulty. Any patient who has a long-standing violent cough, with 
dyspnea, hoarseness, pain in the arm, and a dull area over the manu- 
brium, with negative heart and lungs, has either aortic aneurysm or medi- 
astinal tumor in all human probability. To this residual problem I will 
return later. 

The great interest of the case centers in the three years which have 
led up to the appearance of the present distinctive symptoms of medi- 
astinal pressure. Until very recently this case was regarded, as most 
such cases are, as one of u rheumatism. , ' I have taken occasion in vari- 
ous parts of this book to illustrate the dangers and fallacies inherent in 
most diagnoses of rheumatism. No other word in the doctor's vocabu- 
lary stands so frequently for a dangerous mistake, one for which the 
physician bitterly reproaches himself when he discovers it. How are 
these dangers to be avoided? 

1. Let us never use the word rheumatism unless there is evidence of 
acute infection, with distinct and predominant involvement of joints. 
Muscular pains will then be ruled out, their distinguishing characteristic 
being an increase of pain, especially when the muscle is used. The 
recognition of nerve pains, distinguished by the close relation of the 
suffering to the anatomic distribution of one or more nerves, will still 
further to restrict the unchartered freedom with which we pronounce the 
word "rheumatism." Pain due to inflammation involving the subcu- 
taneous tissues or deeper parts may ordinarily be recognized by the other 
familiar evidences of exudation (tenderness, redness, swelling, heat). 

2. When muscular pains, neuralgias, and subcutaneous exudations 
are excluded, we have left a very large group of lesions in or near the 
joints — bony outgrowths, periosteal inflammations, septic and tubercu- 
lous osteomyelitis, malignant disease of the bone, cartilage, or perios- 
teum, joint fringes and foreign bodies, joint atrophies, traumatic syno- 
vitis, gout, hemophilic arthritis, joint suppurations, and other less com- 
mon affections. From all these true rheumatism (i. e., acute infectious 
polyarthritis oj unknown origin) may be distinguished, in the vast major- 




Fig. 56. — Physical si^ns in a case characterized for nearly three years by pain in the arms. 



PAIN IX THE ARMS 329 

itv of cases, by the fact that it produces no permanent changes in any of 
the joint structures and gives a negative x-ray picture. Joint fringes, 
traumatic synovitis, and suppurative arthritis may show nothing charac- 
teristic in the .r-ray picture, but the history and the accompanying symp- 
toms usually make the diagnosis clear. The point which must be in- 
sisted upon, however, is that if we are to be even approximately secure in 
a diagnosis of rheumatism we must have a satisfactory x-tsly picture of 
the joint in any case persisting over two weeks. 

3. It is, I trust, worth while to mention here some of the diseases 
which I have known frequently diagnosed as rheumatism. The list 
includes many cases of tabes dorsalis, aortic aneurysm, and osteomyelitis 
iseptic or tuberculous), a smaller number of cases of malignant disease 
involving the mediastinal, prevertebral, or abdominal glands and the long 
bones; also a good many cases of pressure neuritis (due to spondylitis, 
subacromial bursitis, or cervical rib). 

Returning now to the case under discussion, we must attempt a 
diagnosis between aneurysm and mediastinal tumor. The strongest 
evidence against tumor is the long duration of the symptoms without 
any involvement of the external lymphatic glands and without more ob- 
vious depression and exhaustion of the patient's physical condition. 
As has been already said, diagnostic problems involving the differentia- 
tion between aneurysm and mediastinal tumor are usually settled sooner 
or later by the discovery of aneurysm. 

Outcome. — The #-rav confirmed the diagnosis of aneurysm. On 
the eighth of January a diastolic murmur was noted, best heard at the 
apex. The pulse showed no change. At times the murmur was loudest 
in the anterior axillary line in the fifth space, and could be heard indis- 
tinctly as far back as the posterior axillary line. The murmur was long 
and wholly replaced the second sound at the apex. Gelatin injections 
produced great pain, but no relief. 

The patient left the hospital on February 24th. 

Diagnosis. — Aneurysm (called rheumatism). 

Case 165 

A washwoman of fifty-nine entered the hospital February 10, 1908. 
Three years ago she had what she was told was a benign tumor in the 
left breast, which was removed in September, 1905. Otherwise, she has 
veil until three months ago, when she began to notice pais on motion 
of the right upper arm and shoulder. Since Christmas, 1907, she has 
able to do little or no work. Until very recently there has been no 
pain when the arm is kept still. Coughing produces pain; breathing 



33° 



DIFFERENTIAL DIAGNOSIS 



does not. For two weeks she has had a somewhat similar soreness in 
the right groin and hip. 

Physical examination showed no emaciation, normal temperature, 
pulse, respiration, blood, and urine. The chest and abdomen were 
also normal, but it was found that the patient could not raise the right 
arm without marked pain. The greatest tenderness was in the front of 
the upper arm. There was no atrophy. 

Counterirritation and small doses of morphin did not relieve the pain 
at all. On the nineteenth it was found that the right arm and the right 
side of the chest were almost completely anesthetic. An orthopedic 
consultant considered the case one of subacromial or subcoracoid bursitis. 
A neurologic consultant agreed. The pain in the right groin disappeared 
after a short stay in the hospital. 

Discussion. — Against the diagnosis of subacromial bursitis the most 
important datum is the area of anesthesia, which involves not only the 
right arm, but the right side of the chest, and was apparently overlooked 
by the other consultants. I have never heard of a bursitis producing so 
wide-spread an anesthesia. Less important considerations antagonistic 
to the diagnosis of bursitis are the absence of any trauma or of any evi- 
dence that abduction or rotation is especially painful, and the fact that 
the pain is not especially worse at night. In the great majority of cases 
of bursitis the opposite is true. 

Three months' suffering with shoulder pain and disability, associated 
with so wide-spread an anesthesia, should always lead at once to the in- 
vestigation of the mediastinum by radioscopy, especially since we have 
no positive evidence that the mammary tumor removed in 1905 was as 
benign as the patient had been led to suppose. 

Outcome. — X-ray taken on the twenty-sixth showed a wide shadow 
in the mediastinum. On March 4th the patient began to complain of 
a smothering sensation in the chest, and some edema appeared in the 
right hand. The veins in the neck, especially on the right, now began 
to be engorged, though the pain was diminished. The patient left the 
hospital March 21st, not relieved. 

Diagnosis. — Mediastinal neoplasm (metastatic). 

Case 166 

J A clerk of forty -nine entered the hospital June 25, 1908. He had 
previously been in the hospital twenty-two years before, suffering from 
what was considered facial neuralgia, but since that time he had been 
perfectly well until five months ago, when he began to have sharp pain 
under the right shoulder and finally down the whole of the right arm. 



PAIN IN THE ARMS 



33 1 



After the first two or three days the pain never bothered him at night, but 
seven weeks ago it compelled him to give up work. He has had to have 
morphin for it once. The pain is most severe near the elbow. The joints 
do not seem to be involved. There is no limitation of motion. His 
appetite and sleep are poor. For a month he has had five or six loose 
movements of the bowels a day. 

Physical examination was entirely negative. There was no tender- 
ness along the course of the nerve-trunks. A"-ray showed nothing ab- 
normal in the chest, the neck, or in the joints. On the second day of 
his stay in the hospital he had a return of the facial neuralgia, which he 
had not previously had for twenty-two years. 

Discussion. — Neuralgia, i. e., nerve pain of unknown origin, is 
always an unsatisfactory diagnosis, and one that we should make with 
the greatest hesitation and as a consequence of a long process of exclusion, 
whereby all known causes for such a pain are sought for without result. 
In the present case we can make a diagnosis of neuralgia only by satis- 
fying ourselves that there is: 

(a) No relation to exertion (angina pectoris). 

(b) No injury of the part (unrecognized fracture, traumatic neuritis, 
contusion or traumatic traction of nerve-trunks, tearing of muscular, 
capsular, or ligamentous fibers). 

(c) No evidence of bursitis (limitation of motion, tenderness at the 
point of the shoulder or in the region of the bicipital groove). 

(d) No signs of inflammation involving the veins, lymphatics, or sub- 
cutaneous tissues. 

(e) No local lesion of the bone or periosteum (septic or tuberculous 
osteomyelitis, periostitis, benign or malignant neoplasm). 

(f) No evidences of pressure, such as cervical rib, aneurysm, mediasti- 
nal, supraclavicular, or axillary glands, or pulmonary tumor. 

(g) No atrophic or hypertrophic arthritis (x-ray evidence). 
(h) No occupation neurosis. 

(i) No systemic, infectious, or vertebral disease. 

In the present case it seems possible, by rigid cross-questioning and 
examination, to exclude all these possibilities. We had reason to believe 
that the patient was already subject to nerve pain of unknown source. 
The diagnosis of brachial neuralgia was, therefore, finally made. 

Outcome. Under aspirin, 10 grains every hour for eighteen hours, 
hot and eold douching, rest, and generous diet, the pain was very much 
relieved by the second of July. On the seventh he left the hospital prac- 
tically well. 

Diagnosis. Neuralgia. 



33 2 DIFFERENTIAL DIAGNOSIS 

Case 167 

A colored housewife of twenty-eight entered the hospital July 23, 
1907. She has never menstruated, but has otherwise been well until 
seven days ago, when she woke up with a sore throat and stiffness through- 
out the whole left side, such that she could not raise her arm or leg. 
Since then she has had much pain in both arms and has taken a great 
deal of morphin. At entrance the arms, knees, and lower legs were 
tender and swollen, the tenderness being as great in the muscles as at the 
joints. Physical examination was otherwise negative, though the tem- 
perature ranged between ioo° and 101 F. for a week, gradually falling 
to normal in the course of another week. The blood showed a moderate 
polynuclear leukocytosis. The urine contained bile for the first five days, 
and she had severe nose-bleed several times in the first four days of her 
stay. The conjunctivae were distinctly bile-stained. 

Discussion. — It seems obvious that we are dealing with an infection 
of some kind. The well-marked pyrexia, the jaundice (hemolytic pre- 
sumably), the polynuclear leukocytosis, and the evidences of local in- 
flammation all point to a bacterial origin. 

Swelling of the extremities is not a common symptom when the heart 
and kidneys are sound, as they appear to be in this case. This is especi- 
ally true of the arm. Occlusion of the vein by infectious thrombosis 
should produce a well -localized cord-like induration along the course 
of one or more veins. We have nothing of the kind here. 

Lymphangitis is usually the result of some infection involving a break 
in the skin. It generally produces a red blush, extending from the point 
of injury or its neighborhood up the extremity toward the nearest lymph- 
glands. But of such an inflammation there is no evidence. 

Of septic myositis we know so little that it is hard to make any definite 
statements about it in a diagnostic discussion. I have never heard of so 
diffuse a myositis except that resulting from the disease next to be men- 
tioned. 

Trichiniasis might produce almost all the symptoms in this case, 
though it is not often limited to the extremities and rarely associated with 
so much edema. 1 The patient's color, the polynuclear leukocytosis, and 
the absence of the eosinophilia strengthens the case against trichiniasis. 

With the exclusion of all these possibilities, there is nothing left but 
an inflammation of the subcutaneous tissue and joint structure, not in- 
volving the veins or lymphatics, not due to an infected wound or to any 

1 A case of trichiniasis involving still more wide-spread edema was reported by Dr. 
Donald Gregg in the Boston Med. and Surg. Jour., December 3, 1909. 



PAIX IX THE ARMS 



006 



known parasite. In the great majority of such cases the tenderness and 
swelling soon ''settle" in the joints, leaving the other tissues free. Be- 
cause of this fact and because the joints ultimately recover entirely, such 
cases are usually labeled ''rheumatism." For the reasons previously 
discussed on p. 328. I believe this term should be restricted to articular 
disease involving no permanent joint changes nor lesions of the subcu- 
taneous tissues around the joints. The present case, therefore, should 
be labeled provisionally as a cellulitis and arthritis of unknown origin. 

Outcome. — The patient was given hot fomentations surrounding the 
extremities, and 10 grains of sodium salicylate every hour. By the 
third of August she was greatly improved. By the thirteenth she was up 
and walking about, all pain and swelling having gone except from the 
left hand. This also gradually got well in the course of six weeks. 

Diagnosis. — Infectious cellulitis with arthritis. 

Case 168 

An unmarried girl of eighteen has always been well save for a bunch 
over the left collar-bone which formed five years ago, broke and dis- 
charged for several months. 

For six months she has had slight pain and considerable disability 
in right shoulder. Rotation is painful and creaky, but abduction is 
not especially limited. The deltoid is very weak and markedly atro- 
phied. 

Physical examination, including temperature, pulse, respiration, 
blood, and urine, is otherwise negative. 

Discussion. — Weakness, soreness, and stiffness of the shoulder 
lasting six months make a clinical picture raising many diagnostic 
possibilities before our minds. Since the general physical examination 
reveals nothing abnormal in the internal viscera or in any other part of 
the body, we are justified in fixing our attention upon the local lesion. 

Subacromial bursitis might produce all the symptoms here described, 
but the history does not suggest any of the ordinary causes of this disease, 
such as trauma, prolonged fixation, or sepsis. If subsequent examination 
Cv-ray) reveals no other disease of the bone or joint, bursitis will present 
strong claims upon our, notice. 

Tuberculous osteomyelitis involving the head of the humerus might 
also account for all the symptoms of which this patient complains. The 
fact that she has previously had a chronic suppuration originating in 
a bunch on the left side of the neck (presumably a tuberculous gland) 
inclini ard the belief that the bone also is tuberculous. Although 

there is no apparent involvement of the soft parts overlying the joint, 



334 DIFFERENTIAL DIAGNOSIS 

the tuberculous process may be confined to the destruction of bone 
(caries sicca). Further evidence must be sought by x-ray examination. 

Only by this means can we exclude an unrecognized fracture oj the 
upper end oj the humerus. It would be strange, however, if, in a 
young girl apparently free from disease of any other part of the body, 
we should find a fracture of the humerus without any known trauma. 
In the early stages of such a lesion the history should have mentioned 
the presence of ecchymosis and swelling, especially on the inner side 
of the arm. Six months after the time of fracture we should expect 
the symptoms either to be gone altogether or to be associated with some 
bony deformity. 

Circumflex paralysis rarely occurs without some much more obvious 
cause than is stated here. In case of such a paralysis there would be 
no visible or palpable contraction of the deltoid fibers if the patient 
were to make an effort to raise the arm (abduction). In the present 
case there were distinct wrinkling and hardening of the deltoid under 
the palpating hand during the patient's effort, although no considerable 
motion resulted. 

Atrophic or hypertrophic arthritis would be almost certain to involve 
some other joint to a greater or lesser extent. The age and sex are 
typical for atrophic arthritis, not at all so for hypertrophic lesions. 
Further evidence regarding such disease could only be obtained by v-ray 
examination. 

A deep axillary abscess, small and high up under the pectoral, 
sometimes produces a fixation of the shoulder-joint and pain on any 
motion involving it; but careful examination of the upper axilla behind 
the pectoral should disclose a deep tenderness and induration, and there 
should be some fever. In the present case such an abscess is unlikely 
on account of the long duration of the symptoms. 

Outcome. — X-ray showed considerable necrosis of the head of the 
humerus, which was therefore excised. Examination of the portion 
resected showed tuberculosis. The girl ultimately made a good re- 
covery, with very fair use of the arm. 

Diagnosis. — Tuberculosis of the humerus. 

Case 169 

An Armenian factory hand of thirty-one received a blow on the 
right shoulder six weeks ago. Afterward the shoulder swelled and 
stiffened. The patient is not able to give any more detailed history 
of his illness. 

Examination. — There is almost complete loss of active motion in 



PAIN IN THE ARMS 335 

the right shoulder. Passive motions are also somewhat restricted in all 
directions; there is marked tenderness over the upper third of the 
humerus. Xo swelling, no hollowing of the deltoid, but marked atrophy 
of the whole upper arm. The axilla is full of tender glands. 

Temperature, ioo° to 103 ° F.; leukocytes, 8000. 

Discussion. — The signs seem to point toward some type of osteo- 
myelitis, but why does not the man get well? Why are there atrophy 
of the whole arm and such marked loss of power in the shoulder? Six 
weeks of disuse might alone cause atrophy and limitation of motion. 
Is there some malignant disease behind it all, some lesion of the central 
nervous system, or tuberculosis? The presence of temperature and 
tender axillary glands tends to show that there is still infection going 
on. although the leukocyte count is so low. The fact last mentioned 
inclines us slightly toward tuberculosis as the cause of the osteomyelitis. 

Obviously, however, the chief need of the case is for an v-ray examina- 
tion, to be followed in all probability by a more thorough investigation 
of the conditions below the deltoid. 

Cases of this type offer an extensive field of possible alternatives for 
differential diagnosis. The history of trauma makes it necessary to 
consider fracture or dislocation of the humerus and subacromial bursitis. 
Contusion or hematoma would presumably have been well before the 
end of six weeks, but there may always be an element of traumatic 
neurosis in the case. 

( )n the other hand, it is essential to remember that the history of 
trauma is often evolved quite out of whole cloth by the patient, whose 
mind imperatively demands some such explanation for a painful and 
tender swelling, due, in fact, to neoplasm, to tuberculosis, to septic 
osteomyelitis, or other disease in which trauma plays a very subordinate 
role. 

Further, we must realize that a subacromial bursitis is sometimes 
brought about by the prolonged immobilization of the shoulder resulting 
from a shoulder contusion which is coddled by a neurotic patient or an 
overanxious mother. 

Taking lip now these alternatives, we may eliminate fracture and 

dislocation by the negative results of x-ray examination; bursitis, by 

the absence of characteristic limitations of mobility; neoplasms, by the 

v. The tend distinctly suggestive of osteomyelitis, 

[ally if neoplasm can be ruled out. The results of exploratory 

ill be important liere. Tuberculosis, whether in the form 
I or whether including subcutaneous tissues, should be 
■• n up by the- results of x ray examination. 



33& 



DIFFERENTIAL DIAGNOSIS 



Outcome. — X-ray showed a large cavity in the head of the humerus 
and a smaller one in the shaft; shoulder-joint obliterated. After opera- 
tion, the patient recovered. The excised bone showed no tuberculosis. 

Diagnosis. — Septic osteomyelitis. 

Case 170 

Two months ago a teamster's left arm suddenly became stiff and 

pained at night near the neck of the humerus. Two days later the 

fingers and palm began to swell and to get shiny. Three days after this 

the whole arm swelled. The pain then extended into the upper back. 

He was then treated in the South Framingham 

hospital for neuritis, and was two weeks in bed, 

but without fever. Now he is much better. 

Edema gone. 

Examination. — All motions of the left shoulder 
were made voluntarily. The muscles were still 
very weak, and there was tenderness over the 
scapula, which later improved with counterirrita- 
tion and sodium salicylate. X-ray negative. 

Discussion. — The earlier symptoms remind 
us of tuberculosis of the humerus or of sub- 
acromial bursitis. But neither of these diseases 
produces so much swelling of the lower arm. 
Tuberculosis may be, with reasonable probability, 
excluded by the negative results of x-ray ex- 
amination, bursitis by the absence of spasm or 
characteristic limitation of motion and the pres- 
ence of diffuse extensive edema. 

This edema might be explained by the pres- 
sure of an intrathoracic tumor or a cervical rib 
upon the veins of the arm, but the fact that the edema so promptly 
disappeared and that physical examination shows no evidence of these 
causes of pressure, suffices to exclude them. 

Swelling of the arm without obvious cause is occasionally due to a 
thrombophlebitis, but such a diagnosis cannot be made unless we find 
induration and tenderness along the course of some vein or veins. 

Brachial neuralgia is a possible diagnosis, although the presence of 
edema and the absence of tenderness following sharply the course of any 
known nerve make it rather unlikely. 

Diffuse inflammation of the subcutaneous tissues (so-called cellulitis) 
is not, in my opinion, a very rare condition, even in the absence of any 







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PAIX IX THE ARMS 



337 



known cause. We hear but little of such affections, because they are 
apt to be called muscular rheumatism, as the present case was. In view 
of the outcome of the case cellulitis seems to me to be the best diagnosis. 

Outcome. — The patient made an uneventful recovery in the course 
of three weeks. 

Diagnosis. — Cellulitis. 

Case 171 

A housewife of thirty-rive has suffered for many years from " rheuma- 
tism " in her right shoulder. 

For three years the pain has been worse and has been referred especi- 
ally to the region of the right clavicle and to the whole right arm. Some- 
times it is localized at the lower end of the ulna. 

Within a month she seems to be losing strength in the arm, and the 
pain often keeps her awake at night. 

Examination shows a pulsating mass above the left clavicle, with a 
sense of firm resistance below and around it. Backward motions of the 
arm cause sharp pain. The outer side of the pulsating mass is \ •en- 
tender. There is no considerable atrophy or limitation of abduction. 
Temperature range, 98 ° to 99.5 ° F. Pulse, 90 to 120. Urine pale, 
acid, 1016; albumin, slightest possible trace. Sediment. Numerous 
blood-globules; small round mononuclear cells, some of which are fatty. 
Many calcium oxalate crystals. Internal viscera negative. 

Discussion. — The diagnosis was not suspected in this case until the 
conditions we^e actually seen at operation. This seems to me wrong, 
for there are very few causes which produce a pulsating mass above the 
clavicle. Aneurysm is naturally our first thought, but this is a very un- 
usual place for an aneurysm, although diffuse dilatations of the sub- 
clavian or carotid arteries often occur as a result of aortic regurgitation 
and in connection with a diffuse dilatation of the arch. This condition 
is not aneurysm, and should not be confounded with it, since there is no 
breaking of the arterial coats and no tendency to end in rupture of the 
artery. Further, an aneurysm of two years' Standing is very rare in this 
situation, and the source of the marked resistance around the pulsating 
ould not be explained by the diagnosis of aneurysm. 

Can the pulsation be transmitted through some tumor or glandular 

by a normal artery beneath? It would seem very unlikely that a 

tumor which would produce pri 'ins in the arm for three years 

should not have attained greater size and pulled the patient down more, 

and metastasis would probably have occurred. 

The pr< ;l slight fever gives some < olor to the idea of gland- 



33& DIFFERENTIAL DIAGNOSIS 

ular tuberculosis, but such a process rarely if ever causes much pain, and 
would scarcely have existed so long without abscess formation. 

Brachial neuralgia is a diagnosis which one never has a right to make 
in the presence of anything which can possibly be interpreted as a 
mechanical cause of the pain under investigation. With a mass like 
that here described the diagnosis of neuralgia has no justification. 

A pulsating mass above the clavicle means cervical rib in nine cases 
out of ten, the pulsation being due to the subclavian artery which over- 
lies the rib, while brachial pain results from pressure on the brachial 
plexus. 

The firm resistance below and around the pulsating mass was the 
rib underlying the artery. Had an x-ray been taken, the diagnosis should 
easily have been clinched before operation, but even without an x-ray 
one might make a reasonably certain diagnosis on the history and physical 
signs, provided one had ever seen a similar case. 

Outcome. — The brachial plexus and subclavian artery were found at 
operation to be elevated on the blunt head of a cervical rib which joined 
the first dorsal rib about two inches from the sternum. 

After excision of the cervical rib the pain disappeared within ten 
days and did not return. 

Diagnosis. — Cervical rib. 

Case 172 

A very alcoholic clerk of thirty-three was sent into the hospital for 
"osteomyelitis humeri." He has had three months' pain in right upper 
arm, at times sharp; occasionally it shifts to the elbow or forearm. Day 
and night make no difference. 

One month ago it began to swell and the soreness and tenderness 
increased. Otherwise he feels well.. 

Examination. — Whole upper right arm 2\ inches larger in circum- 
ference than the left. Hard (bony?) enlargement is felt beneath the 
muscles. The whole mass is hot and tender. 

A plexus of veins is prominent over upper inner side of the arm. 

Discussion. — The fact of enlargement of the upper arm below 
the shoulder and at the point of pain excludes many of the conditions 
discussed in previous cases. Subacromial bursitis, arthritis of the 
shoulder-joint, circumflex paralysis, brachial neuritis, tuberculous 
disease without abscess formation (caries sicca), all produce atrophy, 
not enlargement. 

The heat and tenderness dispose us to consider a septic osteomye- 
litis, a periostitis, or a tuberculosis with abscess and infiltration of the 



PAIN IX THE ARMS 33O 

overlying tissues, but in such diseases one would expect fluctuation 
rather than such extreme induration. Rarely, moreover, does an osteo- 
mvelitis or periostitis result in enlargement of the superficial veins. 

Syphilitic disease of the bone, or gumma involving the skin, would 
probably produce far less pain and little or no enlargement. After 
three months' duration there would almost certainly be some involve- 
ment of the skin, some discoloration or ulceration. 

The enlargement of the veins associated with an increase in the size 
of the whole arm, with marked induration, is very characteristic of 
malignant disease involving the bone. 

Outcome. — X-ray examination showed only a slight increase in the 
area of bone-shadow — apparently a periostitis. The Wassermann 
reaction was negative. Operation showed osteosarcoma. 

Diagnosis. — Sarcoma humeri. 



Case 173 

A school-boy of twelve was struck on the right arm just below the 
shoulder eight weeks ago. The arm became at once swollen, and in the 
past few weeks has been so painful as to require morphin, especially at 
night. 

Examination. — A swelling one-half the size of an orange occupies the 
deltoid region, and extends one-third of the way down the arm, about 
half encircling it. The shoulder motions are free and painless. The 
veins over the lower portion of it are enlarged. The mass is rather 
soft, very tender, and apparently adherent to the bone. One enlarged, 
non-tender gland is felt in the right axilla (normal microscopically). 

Discussion. — The acute swelling and pain near the head of the 
humerus are rather characteristic of septic osteomyelitis, especially in 
a boy of this age. But in the course of eight weeks one would rather 
expect that the pus would have burrowed to the surface or brought 
about a general septicemia. 

Experts in legerdemain accomplish their tricks by setting a trap 

;r attention and attracting our gaze to the wrong place at the wrong 

time. By a similar psychologic mechanism a history of injury like 

this bi one of the commonest and most dangerous of traps set t<> 

catch unwary diagnosticians. Our attention gets concentrated upon 

tp of lesions, such as dislocation, fracture, hematoma, or bursitis, 

which might result directly from trauma. While we are puzzling to 

n these alternatives, or perhaps carrying out treatment 

■ one of them, the actual but unsuspected neoplasm 



34-0 DIFFERENTIAL DIAGNOSIS 

or tuberculosis progresses without hindrance. We forget for the moment 
that osteosarcoma is common in this situation and at this age. 

The plexus of swollen veins over the swelling is rather suggestive of 
tumor, but against it, apparently, is the normal microscopic structure 
of the enlarged axillary glands, which one would expect to find trans- 
formed as a result of metastasis from the bone tumor. It must always 
be remembered, however, that the examination of a gland under condi- 
tions like these sometimes proves very misleading. Twice I have 
known malignant disease of the mediastinum associated with a large 
axillary gland, which, when removed, showed nothing abnormal in its 
structure. Diagnostic conclusions from the examination of glands in the 
neighborhood of doubtful lesions are of value only when the results of 
examination are positive. Negative results are valueless, as was, indeed, 
exemplified in this case by the outcome. 

Outcome. — Incision allowed the escape of some soft material 
resembling grains of sago. On microscopic examination these grains 
showed the structure of round-cell sarcoma. 

Diagnosis. — Sarcoma humeri. 

Case 174 

A boy of ten was sent to the hospital for a tumor of the humerus. 

One month's pain in the right upper arm, with subsequent gradual 
swelling but no tenderness, was the gist of his history. 

Two weeks ago the pain became severe. No known cause. 

Examination. — Looks worn out. Right forearm and upper arm 
swollen (radial pulse good). Motions free. The lower half of the 
humerus is tender. 

Discussion.— The boy is at the age when septic osteomyelitis or 
malignant tumors are apt to attack the end of the long bones. The worn- 
out appearance of the boy and the absence of tenderness rather favor 
tumor, but it is to be noted that tenderness is absent only in the upper 
part of the arm, while the lower part is notably sensitive. 

Why is the whole arm swollen ? We have no evidence of pressure from 
tumor, aneurysm, or cervical rib, no sign of phlebitis or cellulitis. Such 
a swelling would be very unusual were we dealing with tuberculous 
osteomyelitis. 

It does not appear that the diagnosis can be made any clearer with- 
out #-ray evidence or operation. To these procedures, accordingly, 
we must turn. 

Outcome. — X-ray shows thickened periosteum over a swollen 
humerus with a dark area in the middle of the lower one-third of the 



PAIN IX THE ARMS 34 1 

bone. Three ounces of pus were evacuated from a cavity in the medul- 
lar}' portion overlain by thickened bone and periosteum. Staphylococci 
in pure culture from the pus. Temperature, 99 ° to 100 ° F. 

Well in a week. 

Diagnosis. — Septic osteomyelitis. 

Case 175 

A hardwood finisher of forty-seven fell down stairs in 1901, striking 
the right shoulder and the back of the neck. For three months after 
this the shoulder continued sore. 

In 1903 he began to have attacks of sharp pain between his shoulders, 
disabling him from work for several weeks at a time, not relieved by 
any medicine. 

In September, 1904, pain in the nape troubled him and continued 
until January, 1905. In December, 1904, the pain between the shoulders 
and in the right shoulder became severe again, and has lasted until the 
present time (January 17, 1905). This pain is not affected by motion 
or position, but often keeps him awake at night. 

Cough with profuse white sputa, two months. The cough produces 
an increase of pain in the right shoulder and at the root of the neck in 
front. 

Has lost 20 pounds in two years. 

Examination. — Left pupil larger than the right. The patient stands 
with a well-marked stoop. An impulse lifts the manubrium with each 
heart-beat. A diastolic murmur, loudest in the second right space, is 
audible over the whole heart, which shows no obvious enlargement. 
The pulse collapses markedly. The larynx and trachea are normal. 
There are dulness, tenderness, bronchial breathing, and increased voice- 
sounds at the right apex. The right clavicle and shoulder are tender to 
touch, but all motions are free. There is no muscular atrophy. Physi- 
cal examination is otherwise negative. 

Discussion.— The history of the case naturally suggests that the 
present symptoms are due to trauma, especially as the shoulder is still 
tender. But a more careful reading shows that the interval between 
1901 and 1003 is too long for any such explanation. 

Apparently there is no lesion of the joint, muscle, or nerve. All 

articular motion- are free; muscular action does not increase the pain, 
and the suffering is not definitely localized along any nerve trunk. 

The long-continued cough (two months), the emaciation, the ab- 
normal physical signs at the righl apex, and the chest pain had led to 
a diagnosis of pulmonary tuberculosis by tin- attending physician. 



342 



DIFFERENTIAL DIAGNOSIS 



But there seems to be no fever, no evidence of breaking down within 
the lung (rales, purulent sputa), and a great deal more pain in the 
shoulder than one expects to see in phthisis. Especially notable in this 
respect is the long duration of pain before the cough began. There 
seem to have been nearly two years of suffering before there was any 
cough. 

By some orthopedic specialists many pains in the back, shoulders, 
and arms are explained by the so-called "round-shoulder deformity" 
— the ordinary stooping habit. Up to date I have not been convinced of 
the validity of these explanations. The difficulty with all such explana- 
tions is that they fail to show why the stoop has persisted so many years 
longer than the pain supposed to be due to it. In any case it is not at 
all probable that a stoop will be advanced to explain such severe and 
definitely localized pain as is here complained of. 

This patient's pain is in a very queer place. One very seldom 
hears patients complain of pain high up between the shoulders, and when- 
ever one hears such complaints, some cause of intrathoracic pressure 
should be suspected. Such causes are, for practical purposes, three and 
only three, viz., aneurysm, vertebral tuberculosis, and malignant disease. 
Turning now to the circulatory system with the thought of aneurysm in 
mind, we note that there is evidence of aortic regurgitation, such as 
often accompanies aneurysm. We notice also the inequality of the 
pupils, and we are led thus to suspect that the pulmonary lesions may be 
the result of pressure upon the lung itself or upon one of the larger 
bronchi. Obviously, this possibility — aneurysm — has much in its favor, 
especially when we consider the long duration of the symptoms. Intra- 
thoracic neoplasm would probably have produced more obvious and 
alarming symptoms if it had existed so long. Tuberculous or 
other disease of the cervical or upper dorsal vertebrae should pro- 
duce some stiffness or tenderness of the spine, and after so long a course 
some evidences of caseation, telescoping, kyphos, or fever would be 
expected. 

Outcome. — X-ray shows an extensive shadow to the left of the ster- 
num. Had in the ward several attacks of severe precordial pain, with 
great anxiety, relieved by nitroglycerin. Pain then ceased for five 
weeks. 

In March, 1905, he began to have pain in the top of the right shoulder, 
with a scalding feeling in the arm above the elbow. 

The heart apex was then found to be in the sixth space, six inches 
to the left of the median line. The right pulse is smaller than the left, 
and of "Corrigan" type. Tracheal tug. The patient remained in the 



PAIN IN THE ARMS 



343 



hospital until April 6th, suffering very little pain. His treatment con- 
sisted of potassium iodid, aspirin, and laxatives. 
Diagnosis. — Thoracic aneurysm. 

Case 176 

A cook, fifty-nine years old, colored, born in Martinique, entered the 
hospital March 28, 1908. He has always been well except for "rheu- 
matism" many years ago, which attacked many joints but did not keep 
him in bed. He denies venereal disease. 

For two years he has had attacks of pain in the left shoulder, radiat- 
ing thence to the breast-bone and to the pit of the stomach. These 
attacks of pain have come at considerable intervals until within the past 
two weeks, when they have come every other day, and have forced him 
to stop work. The pain is not severe, and is always relieved by rest or 
drinking hot water. He says that his left arm is weak, especially after an 
attack of pain. His ankles have been painful and swollen for two weeks, 
and he has had a hacking cough for five months. At one time he noticed 
that he passed more urine at night than in the day-time, but this is not 
now the case. 

His appetite is good; he has no indigestion and no headache. 

On physical examination the painful shoulder showed no objective 
abnormalities. The cardiac apex seemed to extend one inch outside the 
nipple-line in the fifth space. A systolic murmur was heard at the base 
and down to the fourth left space. The aortic second sound was faint, 
the pulmonic second sound somewhat louder, but not accentuated. 
The pulses seemed to be of high tension, but the blood-pressure read 
only 138 mm. of mercury. The radials and brachials were markedly 
thickened and tortuous. The edge of the liver was felt two inches below 
the ensiform. In the fourth left interspace, near the sternum, a faint 
diastolic murmur was later made out. At no time was there any capillary 
pulse or Corrigan pulse. X-ray was negative. 

Discussion. — We may exclude all varieties of arthritis (rheumatic 
and other), because the joints are at present normal. Muscular, 
periosteal, and nerve lesions can be ruled out by the absence of swelling, 
tenderness, and heat, the absence of any relation of the pain to muscular 
movements or to the anatomic position of the nerve. There is no 
important evidence pointing to any source of pressure within the chest. 

When these possibilities are excluded, we note that the pain conies 

in paroxysms which are relieved by rest, and that it has very wide 

radiation*. Any pain of this type occurring in a man of lilt}' nine 



344 DIFFERENTIAL DIAGNOSIS 

suggests aneurysm or angina pectoris, especially if the patient is a 
negro. Of aneurysm we have no definite evidence, though it cannot 
be ruled out without x-ray examination. Most cases of angina pec- 
toris are associated with a greater elevation of the blood-pressure, but 
the disease cannot be ruled out on that account. Angina is, there- 
fore, the most reasonable diagnosis. Greater certainty can be attained 
through the therapeutic test, but only time can exclude aneurysm. 

Outcome. — The patient was given 5 grains of potassium iodid 
three times a day, with -^ grain nitroglycerin and cascara as needed; 
later, 15 minims of tincture of digitalis three times a day Were added. 

By April 4th he had made marked improvement, and was sleeping 
soundly every night. On April 5th he was out of bed, and thereafter 
was almost free from symptoms until his discharge on the eleventh. 

This case is introduced as an example of a somewhat unusual dis- 
tribution of pain in angina pectoris. In other cases the pain may be 
wholly epigastric, wholly or largely in the arms or in the back. We 
are justified in grouping all these widely separated pains under the 
single heading of "angina," because all of them are associated with 
arteriosclerosis and with cardiac disease which is fairly well compen- 
sated. It is important that all of them are produced and relieved in 
the same way. The four specially characteristic occasions for anginal 
pain are all of them occasions of suddenly raised blood- pressure. These 
are: 

\a) Muscular exertion. 

(b) Strong emotion. 

(c) Digestion, especially if it be impeded in any way. 

(d) Getting up in the morning. 

The vast majority of anginal attacks are produced by one of these 
four causes, which I have arranged in the order of their frequency. 
Much less common is angina that wakes the patient from sleep. The 
relief of pain when one of these causes has been removed usually enables 
the patient and his physician to be quite clear as to its cause. The 
relief by some one of the nitrite preparations, which tend to lower 
blood-pressure, is also of great diagnostic value. 

Diagnosis. — Angina pectoris [syphilitic aortitis?]. 

Case 177 

A tailor of sixty entered the hospital July 21, 1906. He stated 
that for eight or nine weeks he had had rheumatism in his right shoulder, 
which is now much better and troubles him very little. A little later 
he noticed a lump just above and to the right of his breast-bone. This 



PAIN IN THE ARMS 



345 



has gradually increased in size until the last week, when it has grown 
very rapidly. It is hard, not tender, and seems to "beat." He now 
notices pain on lifting his right arm or turning on his right side. There 
is no history of injury. For the past two months he has been hoarse. 

Physical examination shows that the pupils are equal and react 
normally, though they are slightly irregular. The heart shows nothing 
abnormal. To the right of the sternum, above the second rib, is found 
an expansile, pulsating tumor, the size and shape of an egg. The 
right clavicle is pushed forward, and the sternal end seems to be buried 
in the tumor. The manubrium is eroded and the first rib completely 
cut off from the sternum. There is no dulness beneath the manubrium, 
an4 no other abnormal pulsation. There is a faint systolic murmur 
over the tumor. 

Physical examination of the lungs, abdomen, extremities, blood, 
and urine is otherwise normal. 

Discussion. — Hoarseness, shoulder pain, irregular pupils, and a 
pulsating lump near the breast-bone seem at first almost indisputable 
evidence of aneurysm, and so, in fact, they did seem to most of those 
who saw this case in the hospital wards. Certain points, however, 
were, at any rate, atypical, to wit: 

(a) The pain: why should it decrease? It rarely does decrease 
in cases of aneurysm unless the patient takes to bed and adopts other 
measures for slowing the circulation. 

(b) The percussion area: why should there be no substernal dul- 
ness? The aneurysm must be supposed to arise from the arch of the 
aorta, and ought, therefore, to produce dulness under the manubrium. 

(c) Aneurysms rarely begin above the level of the sternum in the 
neck or behind the clavicle. Unusual pulsations at this point rarely 
turn out to be aneurysm. 

(d) The patient is rather old for aneurysm, though this by no means 
excludes it. 

(e) An aneurysm situated in this position would probably involve 
the subclavian artery or the innominate sufficiently to produce inequality 
of the pul 

Decisive evidence might probably have been obtained by .v ray 

examination. 

If not aneurysm, what else could this lump be? Gummatous tumors 

immon in this situation. They are not usually painful and destroy 
much less hone than appears to have disappeared in this case. They 

te only in case they have perforated the sternum, which is a rare 
occurreiM 



34^ DIFFERENTIAL DIAGNOSIS 

Tuberculosis of the bones composing the thoracic wall usually shows 
more evidence of caseation, produces but little pain and that confined 
to the diseased focus itself, and never pushes the clavicle forward. 

Malignant disease originating in the ribs, in the sternum, or in some 
of the mediastinal structures would produce most of the signs here 
described. The marked pulsation seems less inconsistent with a vascular 
neoplasm than with syphilis or tuberculosis. The patient's age is sug- 
gestive of neoplasm rather than of aneurysm. 

Outcome. — Despite the considerations just adduced, a diagnosis 
of aneurysm was made. The patient left the hospital on the twenty- 
fifth of July, and not long after consulted Dr. Maurice H. Richardson, 
who removed an incapsulated vascular tumor which suggested, on 
histologic examination, a metastasis from hypernephroma. There 
was no aneurysm. Some months later the patient entered the Cam- 
bridge Hospital for profuse renal hemorrhage, probably due to the 
primary tumor. 

Diagnosis. — Metastatic hypernephroma. 

Case 178 

A milliner of twenty-seven entered the hospital March 9, 1907. 
Her family history was negative, and she remembered no illness until 
within the past year, when she has had dysentery with eructations of gas 
after eating, especially after taking fried food. She has had to get up 
to pass water once or twice at night for the past year. For two months 
she has been conscious of her heart-beat. Eighteen months ago she 
weighed 112 pounds, which was about her average weight. Now she 
weighs 97 pounds. 

Three months ago she began to have cough, which sometimes is so 
intense as to make her vomit. She spits almost nothing. For the same 
period she has noticed shortness of breath on slight exertion. January 
30, 1907, she was admitted to the Rutland Sanatorium for tuberculosis, 
and five examinations of her sputa were made, with negative results. 
Her temperature while there was normal the greater part of the time, but 
at irregular intervals it would rise to ioo° or 100.5 ° F. She comes to 
the hospital directly from Rutland. On more careful questioning she 
admits that for a year she has been having dull pains in the left side 
of her neck, and pain and numbness in the left arm. This pain is apt 
to increase gradually for two or three minutes and then suddenly stop. 
Eggnog or anything containing alcohol makes the pain distinctly worse. 
It has quite frequently kept her awake at night. Lying on the left side 
makes it worse. 



PAIN IN THE ARMS 347 

Physical examination shows slight brownish pigmentation of the skin. 
The left chest is somewhat fuller in front than the right, and the veins 
over it are prominent. Over the left clavicle is a small mass the size 
of an English walnut, hard and movable, not tender. The heart is 
negative. The left lung shows dulness just above and below the clavicle. 
Throughout the left front, breathing is distant, and the same is true of 
the left back below the scapula, where there is dulness and diminished 
fremitus as well. The abdomen is negative. The left upper arm 
measures 21 centimeters; the right, 9 centimeters. 

Discussion. — The mistaken diagnosis of tuberculosis was quite 
excusable in this case. Cough, dyspnea, pain, with dulness at one pul- 
monary apex, loss of weight, and a slight pyrexia are certainly very 
strong evidence in favor of tuberculous infiltration. It was only after 
repeated negative examinations of the sputa that it seemed necessary to 
reconsider the diagnosis. The fact that no rales had appeared during 
a considerable period of observation, and especially the early appearance 
and long persistence of pain, began to make it seem likely that some 
deeper and more serious disease was at work. 

The most significant fact in this case is, I think, the long interval 
(nine months) between the beginning of pain sufficient to keep her 
awake and the onset of cough. This, I think, should have made us 
suspicious and doubtful of our diagnosis from the first. 

High Pott's disease must be reckoned with. There need be no 
kyphos in such cases, and the pain is often referred to points distant 
from the spinal lesion. The pain, however, is the only symptom which 
points toward vertebral tuberculosis. We have no muscular spasm, no 
stiffness or torticollis, none of the evidences of caseation or abscess 
formation such as might well be expected after a year's duration of the 
disease. 

When the arm began to swell and the lump appeared above the left 
clavicle, there was no longer any considerable doubt that a mediastinal 
tumor of some type was pressing upon the brachial plexus. Such 
tumors, whether they arise from mediastinal glands, from the root of 
the lung, or from the pleura, usually begin with symptoms of ordinary 
fleural effusion, for which thcv arc frequently mistaken. In their early 
3 there are often no pain, no external tumor, and no swelling of tin- 
arm. The pleural effusion, however, rcaccimiulates with astonishing 

swiftness after aspiration. It mav or may not he bloody, and it^ cellular 

Ments may or may not he identical with those of ordinary (tuber- 
culoi: v. But it is especially the rapid refilling of the chest after- 

tapping that finally awakens <>;ir suspi< ions of malignant disease. 



348 



DIFFERENTIAL DIAGNOSIS 



Outcome. — X-ray of the chest showed a diffuse shadow, chiefly on 
the left side, but extending also a short distance to the right of the spinal 
column. The nodule at the base of the neck was removed and examined 
by Dr. Wright, who pronounced it malignant lymphoma. The evidences 
of fluid at the base of the lung steadily increased. The patient did not 
react to 3.5 mgm. tuberculin. On the twenty-fourth of March she 
was discharged not relieved. 

Diagnosis. — Malignant lymphoma. 



PAIN IN THE ARMS 



349 





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CHAPTER XII 
PAIN IN THE LEGS AND FEET 

Case 179 

A HACKMANof twenty-five entered the hospital March 6, 1907. His 
family history was negative. A year ago he had urethritis and was sick 
for a month. For a week his left ankle was swollen and red and he was 
unable to use it for a month. Six days ago he noticed a cutting pain in 
his right hip, relieved by sitting down. Four days ago he was unable to 
get out of bed. Yesterday his left ankle was swollen and sore. 

Physical examination showed normal temperature, pulse, and res- 
piration. The chest and abdomen were normal. There were slight 
tenderness, redness, swelling, and pain across the instep of the left foot. 
Motions of the right hip caused marked pain in the sacro-iliac joint. 
There was also tenderness there. 

Discussion. — We are dealing with lesions of the right hip and left 
ankle — in all probability some type of arthritis. The diagnosis of 
rheumatism must be avoided like a blasphemy unless we are forced to it 
by the exclusion of all other possibilities. To those possibilities we will 
accordingly turn our attention. 

Hypertrophic arthritis (osteoarthritis) does not attack these joints 
in a man of twenty-five. It will be remembered that in the hip-joint 
this lesion constitutes the malum coxce senilis and leaves youngsters 
unscathed. 

Atrophic arthritis might involve these joints in a young man, but 
always involves other joints as well (particularly those of the hand), and 
it is very prone to a symmetric distribution, e. g., both wrists, both 
ring fingers, both hips, both feet. 

Were the sacro-iliac joint alone affected, it might not be necessary 
to assume the presence of any inflammatory lesion. Some strain or 
displacement of the joint might suffice to produce the pain. But since 
the opposite ankle-joint is also involved, we have no reason to connect 
the two lesions mechanically. Infection is the only other familiar link, 
especially as we have no definite evidence of any metabolic defect, such 
as gout. 

350 



Causes of Pain in Legs and Feet 



1. INFECTIOUS DISEASES (AT ONSET ESPECIALLY) 



2. FLAT-FOOT 

3. INFECTIOUS ) 

ARTHRITIS f 

4. VARICOSE VEINS 

5. TABES 

6. HYPERTROPHIC^ 

ARTHRITIS i 

7. PHLEBITIS 

8. SCIATICA 

9. OSTEOMYELITIS 

10. TUBERCULOSIS 

11. SPRAINED ANKLE 

12. SPRAINED KNEE 

13. SYPHILITIC 1 

PERIOSTITIS I 

14. ATROPHIC 1 

ARTHRITIS I 



16. ALCOHOLIC 
NEURITIS 



15. TENOSYNOVITIS 

} 

17. SARCOMA OF LEG) 

BONES J 

18. GOUT 

19. MORTON'S META-) 

TARSALGIA J 

20. INTERMITTENT j 

CLAUDICATION I 



2204 

789 

513 
313 

265 

205 
157 
136 
134 
130 
56 

46 

44 

33 

29 

17 
16 
14 



34i 



PAIX IN THE LEGS AND FEET 



353 



If the joint troubles are of infectious origin, the first question to 
be answered is: Could a urethritis last so long? Can the joint trouble 
be due to a gonorrheal infection? To answer this question we must 
investigate the urethra. 

Outcome. — A urethral smear showed gonococci. Vaccines were 
given beginning March 8th, and within two days were followed by 
considerable improvement. 

On the seventeenth there was much pain in the sacro-iliac region, 
and this lasted until the twenty-second, after which he improved rapidly. 
The opsonic index was low most of the time until the twenty-eighth', 





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next is the leukocyte count; the third stands for the opsonic index, and the fourth for the 
dose of vaccine. 

after which it rose and staved high. Its variations are shown in the 
accompanying chart. On April 7th he was walking about without 
any difficulty, and on the ninth he was discharged much relieved. 
Diagnosis. — Gonorrheal arthritis. 



Case 180 

A colored man of sixty four entered the hospital July if, igo;. 

Eamily history is negative. He stated thai he almost died of a 

"bad (old" at fifteen, that he had had spinal curvature since he was 

thrown from a horse at fourteen. In the eighties he was at the: Boston 
I \ vlum for a time. 



354 



DIFFERENTIAL DIAGNOSIS 



Since spring his right hip has pained him, and for the last three 
weeks the pain has been so severe as to interfere with sleep, and when 
he wakes there is much pain and stiffness in both legs, though it wears 
of! considerably with exercise. Three weeks ago his feet were swollen 
for some time. This has now gone. He drinks much water and usually 
passes urine three or four times at night. His bowels move every day 
or two, and only with medicine. 

The movements of the patient's pulse, temperature, and respiration 
are seen in the accompanying chart. At entrance his white cells were 
7700, but a differential count showed that 90 per cent, of these were 

polynuclear. There was no anemia. The 
spine showed scoliosis, resulting in a marked 
prominence of the ribs of the left back. 
There was an old bony deformity of the 
right elbow-joint, which was stiff. He w r as 
poorly nourished. There was marked arcus 
senilis. The heart showed nothing of in- 
terest. The radial arteries were tortuous 
and stiff. The front of the chest was nega- 
tive except for a few fine rales over the right 
clavicle. Behind, the right chest was dull 
below the spine of the scapula, with dimin- 
ished or absent breathing; the left back was 
full of moist rales. The abdomen showed 
slight tenderness in the region of the gall- 
bladder. There were glands the size of 
walnuts or almonds in the groins, axillae, 
and neck. There was practically no motion 
in the spine. The urine averaged about 35 ounces during his stay in 
the hospital, with a specific gravity of 1015, a slight trace of albumin, 
and very many hyaline and fine granular casts, with cells adherent, 
some of which were fatty. 

On the fourteenth the chest was tapped and 27 ounces of fluid 
removed, with a specific gravity of 1015, albumin, 2 per cent., lym- 
phocytes, 81 per cent. The sputa showed nothing remarkable. 

From the seventeenth of July until the twentieth he was delirious. 
Discussion. — There appear to be many widely diverging clues in 
this case. The history gives us hints of psychic stigmata, of tuberculosis, 
of renal or cardiorenal disease, of multiple arthritis and multiple adeni- 
tis. Certainly it is a difficult case to untangle. We seem to have 
reasonably good evidence of a chronic interstitial nephritis. The 



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PAIX IN THE LEGS AND FEET 355 

nocturia, the swollen feet, and the character of the urine point in this 
direction, but it is practically certain that he has something else the 
matter with him. 

On the other hand, that "bad cold" which he had at fifteen, follow- 
ing immediately upon the spinal trouble, which appears to have resulted 
in a rigid spine, makes us very suspicious of tuberculosis, especially 
as the symptoms occur in a colored man. The effusion in the right 
chest ^evidenced by dulness and absent respiration) may be due either 
to tuberculosis or to mechanical causes (dropsy). The low specific 
gravity inclines me to believe that the fluid is not a pure exudate. The 
multiple adenitis is not inconsistent with tuberculosis, though it might 
also indicate syphilis. All types of leukemia are excluded by the blood 
examination. 

That some infection has invaded the patient's body seems indicated 
by the continued fever and the delirium. We might suppose that this is 
a terminal sepsis due to the streptococcus or some other of the common 
terminal invaders, the rest of the symptoms being then explained under 
cardiorenal disease. But this would not account for the stiff spine, 
the stiff elbow-joint, the general glandular enlargement, and the early 
history. 

A positive diagnosis seems impossible, but more facts can be ac- 
counted for by assuming a tuberculous infection than by any other 
hypothesis. As a matter of fact, however, this diagnosis was not made. 

Outcome. — He became comatose on July 20th and on the twenty- 
third he died. 

Clinical diagnosis: Arteriosclerosis; chronic nephritis; pleural effu- 
sion; terminal infection. Autopsy showed old tuberculosis of the spine; 
tuberculosis of the kidneys; tubercular ulcer of the ileum; miliary 
tuberculosis of the bronchial lymph-glands, with suppuration; tuber- 
culosis of the lungs, liver, spleen, kidneys, and epicardium. The 
guinea-pig which was inoculated with 25 minims of the sediment of the 
pleural effusion was killed August 23d and showed no evidence of 
tuberculo 

Diagnosis. — See last paragraph. 

Case 181 

A ' per of thirty one entered the hospital November 1, T007. 

Eamily history was negative. Sin- had been operated upon a 
neral Hospital for stone in the right kidney in 
but n< rmd. All the summer of 1 j 7 she had been run do \ a, 



356 



DIFFERENTIAL DIAGNOSIS 



had been easily nauseated, and had vomited frequently. The vomiting 
had sometimes been brought on by worry. 

For five weeks she has been tired, restless, and overemotional. 
Appetite and sleep have been poor. Three weeks ago she first noticed 
that she limped, favoring the right leg. This limp has steadily in- 
creased; and for the past two weeks she has been constantly in bed. 
Two weeks ago she began to have sharp pain in her right groin, in the 
right hip and to some extent in the right lower back. The pain is worse 
at night and often keeps her awake; it comes in paroxysms, leaving her 
entirely for a few hours at a time. When tired, she passes urine every 
two hours or so, but she has noticed no change in it. The course of the 
temperature is seen in the accompanying chart. 

Examination of the chest was negative. 
The abdomen was tympanitic throughout and 
held more rigidly on the left than on the right. 
On deep palpation there seemed to be some ten- 
derness on the right. The right leg was kept 
continually flexed upon the body. Extension of 
the hip-joint or outward rotation was painful; 
other motions were good. The scar of the pre- 
vious operation was seen in the right flank. On 
deep inspiration a rounded, tender mass could be 
indistinctly felt in the right flank. 

Examination by an orthopedic consultant con- 
vinced me that the psoas contraction was not due 
to any hip lesion. The kidney and the mesen- 
teric glands were suggested as possible causes. 

On November 5th and 7th the urine showed 
a large amount of pus in the sediment; a very 
slight trace of albumin; specific gravity, 1013; the 
amount, about 40 ounces in twenty-four hours. 
Discussion. — In this and the succeeding case we are dealing with 
a hip pain associated with a psoas spasm. There seems no evidence that 
the hip-joint or spine is involved. One looks accordingly for the other 
and less common causes which lead to contraction of the psoas. Deep 
tenderness on the right side of the abdomen, associated with fever and 
psoas spasm, is a well-known feature of appendicitis. But appendicitis 
rarely begins with a limp before there is any right iliac pain. It should 
produce some muscular spasm of the abdominal wall, but there is none of 
this here, nor is there any localized tenderness or "cake" over the 
appendix region. 



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case 181. 



of 



PAIX IX THE LEGS AND FEET 357 

Tuberculosis of the mesenteric gland and occasionally other causes 
of mesenteric adenitis may lead to psoas spasm. Such a diagnosis is 
hard to make, harder still to deny. One inclines toward it if there is 
nothing to suggest any other recognized cause of psoas contraction. 
Probably adenitis accounts for some of the mysterious cases of "idio- 
pathic" or "hysteric" spasm of the psoas. Psychic causes are often 
invoked when our diagnostic resources are exhausted. 

Various kidney lesions (hematogenous infection, perinephritic abscess, 
tuberculosis, stone) have been known to bring about a contraction of the 
psoas. This patient has pus in the urine, and an investigation of the 
kidney is, therefore, of the first importance. 

Outcome. — On November ioth the flexion of the leg had become 
more marked. The patient ate and slept poorly. Three x-tsly plates 
were taken. They showed apparently two renal stones on the right. 

Operation November 16th showed two stones and a little pus in the 
kidney. Even under deep anesthesia the leg could not be extended, 
but later, in convalescence, this spasm entirely disappeared and she 
walked well. 

Diagnosis. — Psoas spasm due to nephrolithiasis. 

Case 182 

An Italian hod-carrier of thirty-two entered the hospital June 26, 
1906. Three weeks ago, while carrying bricks on a ladder, he felt a 
peculiar sensation in the left hip, described as "throbbing" (probably 
clonic spasm). Since then there has been pain in the hip, with marked 
stiffness, the pain being increased on motion. 

Visceral examination (including blood and urine) was negative. 
The left thigh was partly flexed, and could not be straightened without 
pain. Flexion and rotation caused no pain. There was no other 
obvious spasm and no tenderness. The left groin was slightly fuller 
than the right. X-ray showed no sign of hip-joint disease, renal disease, 
or of aneurysm, which had been suggested by Dr. Goldthwait in the 
out-patient department; although there was greater pulsation in the 
Is of the affected side, the temperature in both legs was the same. 
There was slight dulness in both Hanks, not shifting on change of posi- 
tion. 

Tuberculin was given, but no rise of temperature followed. 

On July 1st Dr. Goldthwait thought that some libers of the ilio 

re probably ruptured. 
Discussion. In many respects this case resembles the last. In 
studying it we interrogate, by means of physical examination (a) The 



35$ DIFFERENTIAL DIAGNOSIS 

hip- joint; (b) the spinal column; (c) the appendix region; (d) the renal 
region and the urine. We consider enlargements of the mesenteric 
glands, always so easy to include and so hard to exclude in cases of this 
type. We look for evidence of abdominal tumors or aneurysm of the 
aorta. 

In the present case we are able, apparently, to exclude all these 
possibilities except tabes mesenterica, and this, in view of the negative 
tuberculin reaction, seems very unlikely. Since there is no reason for 
accusing the stolid Italian laborer of the "vapors," we have to fall back 
upon a hypothetic strain involving the psoas. There seems no reason, 
a priori, why this muscle may not be subject to strain or sprain like any 
other, but it is obvious that, until we have followed our patient far into 
convalescence, we cannot place any reliance on such a diagnosis. 

Outcome. — By July 9th the patient was walking well, without limp 
or pain. Uninterrupted recovery followed, apparently as the result of 
the magnificent air which he breathed in the surgical wards of the 
Massachusetts General Hospital. 

He was given no other treatment. 

Diagnosis. — Psoas tear (?). 

Case 183 

A beef-carrier of fifty-three entered the hospital January 29, 1907. 
His family history is negative. He has never been sick until the present 
illness, but has been in the habit of getting drunk once to three times a 
week. Two weeks ago he woke in the night with a pain in the right 
hip. Since that time he has been confined to bed with pain and fever, 
wandering in his mind, and constant twitching of the arms. His wife 
says he has had no alcohol for two weeks. He has been treated for 
lumbago and for diabetes. Later it was learned that five years ago he 
had had some abscesses on his neck which discharged for a year. They 
were finally cured by an extensive operation. 

Physical examination showed good nutrition, but the patient's 
mind was cloudy, though he would answer simple questions. All his 
muscles were held rigidly, especially those in the neck and arms, but 
there was no paralysis. The pupils were slightly irregular, but reacted 
normally. The eye motions were normal, the chest and abdomen 
negative. The white cells were 13,000; the Widal reaction suggestive, 
but not positive; the blood otherwise normal, likewise the urine. Marked 
subsultus was the most prominent feature. At entrance the case was 
taken for an acute abdominal emergency and immediate operation was 



PAIX IN THE LEGS AND FEET 



350 



fe : fc 



; 



urged. On the second day the patient became unconscious, with pro- 
fuse sweating. 

Discussion. — Hip pain, fever, and delirium are the presenting 
svmptoms. The character of the delirium suggests alcoholism, but 
two weeks' abstinence from alcohol should have steered him past the 
danger of delirium tremens. The general muscular rigidity, moreover, 
the hip pain, and the irregularity of the pupils could not be 
thus accounted for. 

The mental condition, the muscular twitchings, the fever, 
and suggestive AYidal reaction furnish us with some of the 
material whence a diagnosis of typhoid might be built up. 
But the leukocyte count is remarkably high for that dis- 
ease, and we should still be left without an explanation of 
the hip pain, the muscular rigidity, and the condition of 
the pupils. 

Rigidity* of the neck in a febrile patient always makes 
us fear meningitis, and all the other facts in this case go to 
strengthen this hypothesis. If he had been treated for dia- 
betes, as the history states, he has probably had sugar in 
his urine. Transient glycosuria is not uncommon in 
meningitis of any type 

But if he has meningitis, can we in any way explain 
the hip pain? Certainly not by the epidemic or aural type 
of meningitis, but meningeal tuberculosis might well origi- 
nate in a tubercular hip, the probability of which is in- 
creased as we note that he has had chronic discharging 
abscesses of the neck, presumably tuberculous. 

Outcome. — He died on the thirtieth of January. Autopsy showed 
tuberculosis of the bodies of the fourth and fifth lumbar vertebra 4 , with 
large psoas abscesses; tubercular meningitis; tuberculosis of the retro- 
peritoneal glands; obsolete tuberculosis of the left apex. 

Diagnosis. — Pott's disease with psoas abscess. General tuberculosis. 




Fig. 61.— 
Chart of 
case 183. 



Case 184 

An architect of thirty entered the hospital May 3, 1907. His family 
history, past history, and habits are good. I ive weeks ago, while 
jumping to catch a base ball, he felt a sharp pain in the left hip. Eta 
got home with difficulty, and lias been in bed ever since, suffering 
almost continual pain in the left hip and along the back of the thigh. 
Opiati been necessary to produce sleep, and even then only a 

i ours' sleep at a time has been obtained. The pain has iicur been 



360 DIFFERENTIAL DIAGNOSIS 

in the back and has gradually diminished in intensity, but the patient 
is still unable to walk or to put the foot to the ground. The left thigh 
is held slightly flexed, and there is a tender point two inches outward 
and upward from the tuberosity of the left ischium. There is also 
tenderness along the course of the sciatic nerve, but none over the sacro- 
iliac joints. It was afterward learned that five years ago he had a 
similar attack, following bicycling; he was then laid up for five weeks. 
Later he brought on another attack by jumping while playing tennis. 

Discussion. — As in the previous case, the presenting symptom is 
sciatic pain, but here its origin is not insidious and obscure, but abrupt 
and apparently traumatic. In studying it we must go through the 
same series of investigations intended to bring to light any cause for 
pressure upon the nerve (pelvic tumors, bony outgrowths from the 
femur, spinal osteoarthritis, sacro-iliac displacement) and any metabolic 
disturbance, such as diabetes, whereby a toxic neuritis or neuralgia 
might arise. [It should be noticed in passing that no one seems ade- 
quately to have investigated the possibility that diabetic sciatica may 
be due not to a chemical cause, but to muscular weakness, destroying 
the support of the pelvic articulations. Certainly toneless, flabby muscles 
play an important part in many cases of sacro-iliac trouble.] 

Many cases of sciatic pain seem, like the present one, to begin after 
an injury which is usually of the type here described, i. e., a wrench such 
as might bring about violent extension of the hip- joint and possibly 
some strain or stretching of the sciatic nerve. It has been more fre- 
quently assumed, however, in recent discussions, that the trauma has 
affected the sacro-iliac joint primarily, the nerve only secondarily. 
This seems to me to be a matter rather of fashion than of reasonable 
conviction. 

Outcome. — X-ray showed no evidence of spinal involvement or of 
sacro-iliac disease, and an orthopedic consultant considered the case 
one of "simple sciatica." From the time of entrance until the thirteenth 
of May he was treated, chiefly with a view to relieving the pain, by 
means of ice-bags, hypnotics, and an occasional dose of morphin. On 
the thirteenth he was given hydrotherapy and Zander treatment, which 
within a few days produced remarkable improvement. On the seven- 
teenth he was discharged, much relieved. 

Diagnosis. — Sciatica. 

Case 185 

A farm hand, thirty years old, entered the hospital February 16, 1907. 
Three years ago he had a compound fracture of the right thigh. He 



PAIN IN THE LEGS AND FEET 



361 



was in bed seven months, and has had half an inch of shortening in that 
leg ever since. After being out of bed about a month, he had an attack 
of what was called "sciatic rheumatism," which, so far as he remem- 
bers, was exactly like his present illness. He was then confined to bed 
for two months and was treated by electricity and drugs. He denies 
venereal disease, takes about 25 cents' worth of beer and whisky a week, 
and chews 10 cents' worth of tobacco a day. 

Three days ago, without any known cause, he felt a sharp pain in 
the right hip-joint. This pain has continued ever since, is worse on 
motion or pressure, radiates down the back of the leg to the ankle, 
and is accompanied by a burning sensation, also described as like 
electricity. He has never any pain in his back. He worked until 
last night, but then the pain was so severe that he was unable to sleep, 
even with morphin. This morning for the first time he noticed blisters 
on the leg, due, he thinks, to a poultice. 

Physical examination of the chest and abdomen was negative, except 
for a sausage-shaped mass in the left iliac fossa, which disappeared in 
the course of a couple of days. 

The knee-jerk was very active on the left, less so on the right. On the 
left buttock was a series of vesicles filled with straw-colored fluid. On the 
right, opposite the upper part of the sacrum, and over the thigh, in the 
region of the great trochanter, was a line of ruptured vesicles. Pressure 
over the sciatic nerve, especially near its exit from the pelvis, in the pop- 
liteal space and in the calf, was painful. Sensibility was normal. There 
was no tenderness over the spine or pelvic bones. Rectal examination 
was negative. The pain was excruciating in all positions, and was very 
little affected by morphin. Ice at times gave slight transient relief. 
After the twenty-second the pain became more bearable, following 
the administration of three grains of quinin every two hours until the 
ears rang. Static electricity seemed to increase the pain. Aspirin did 
not help at all. 

Discussion.— The history of pain coming on for the first time soon 

after a severe fracture of the femur naturally directs our minds to the 

bility that by the callus formed at the site of fracture, pressure 

may be exerted upon the sciatic nerve or adhesions formed involving it. 

The difficulty with this supposition is that the patient has been free from 

pain for over two years, although nothing has been done which would 

remove adhesions or alleviate pressure. Possibly there may be some less 

direct connection between the fracture and the present pain, but it is 

beyond the region of conjecture. Only by x-my examina 

nd n-< tal palpation can we gel any further evidence in this direction. 



362 DIFFERENTIAL DIAGNOSIS 

Any sciatica which involves both legs is very suggestive of pelvic 
new-growth. In this case we have apparently a bilateral herpetic erup- 
tion, the usual manifestation of a lesion of the ganglion with its corre- 
sponding nerve-root. The pain, however, is unilateral, and we have no 
definite evidence to support the idea of pelvic new-growth. 

In every case characterized by sciatic pain we should remember 
that diabetes is one of the commonest causes for such pain. There is 
no statement about the urine in the above record of this case, and evi- 
dence should certainly be sought in that direction. 

Largely through the influence of Dr. J. E. Goldthwait the medical 
profession has now learnt to search for osteoarthritis of the lumbar spine 
or for some lesion of the sacro-iliac joint in all cases of sciatic pain. The 
nature of the connection between the pain and the bone lesions has not, 
I think, been fully explained as yet. Most of the important evidence of 
such a connection consists in the results of a therapeutic test — fixation 
of the spinal and sacro-iliac joints by strapping, belt, or plaster-of- Paris — ■ 
and on the relief of symptoms following such fixation. This is of great 
practical importance, but does not answer all the questions regarding the 
mode of production of sciaticas thus relieved. In the present case we 
find no evidence of spinal or sacro-iliac disease. 

The term "sciatic rheumatism " is now happily falling into disuse, 
and with it, I believe, will soon go out of existence the hoary and over- 
worked theory that cold produces such troubles. Doubtless it was their 
connection with joint lesions such as those just referred to that first 
suggested the term "rheumatic," with the theory of cold as the cause. 
In view of the negative result of all the examinations directed toward 
finding a cause for. the pain we shall be obliged to leave it as an unex- 
plained symptom ("primary," " idiopathic," or "simple" sciatica). 
Since it is associated with herpetic eruption, and since we know that 
many cases of herpes are due to infectious disease, it is fair to surmise 
that the neuritis with which we are now dealing may be of the infectious 
type. All this, of course, presupposes that the results of urinalysis and 
^c-ray examination are negative. 

Outcome. — X-ray of the femur showed a large callus with a project- 
ing spicule, but as there had been no pain for two years, this seemed prob- 
ably not responsible for the pain. Dr. J. J. Putnam considered the case 
neuritis with herpes zoster. Dr. Goldthwait agreed. 

On the twenty-fifth the patient was discharged much relieved. 

Diagnosis. — Neuritis with herpes zoster. 



PAIX IX THE LEGS AND FEET 



3£>3 



Case 186 

An Italian pressman of forty-five entered the hospital March 26, 1906. 
Three weeks ago he gave up work on account of pain in his hands and 
feet, which has been severe ever since, and has recently kept him awake. 
His appetite is poor and he has vomited several times. He attributes 
his pain to the fact that he gets very wet with perspiration at his work and 
then rides home upon a car. He got very cold in this way, just before 
the present illness. 

The course of the temperature is shown in the accompanying chart. 
There was soft edema of the backs of both hands. The risrht wrist 



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and left elbow-joint were swollen, slightly stiff, and tender. There was 
tenderness on moving the fingers, and convincing evidence of fluid in the 
left knee-joint. 

Both ankles were somewhat red, swollen, and tender. There was 
tenderness on pressure in the calves of the legs and over the muscles of 
the forearm, a bright red macular rash over his back, with small, shiny 
papules scattered through it, and in the arm pits numerous small, dis- 
crete, transparent vesicles. He was seen by Dr. Goldthwait on the 
twelfth of April. He found at this time an infectious process, chiefly 
in the cellular tissue, with very little involvement of the joints. 

The temperature fell to normal about the twenty eighth of March, 
but on the thirty first the patient was delirious and chattered a great 



364 DIFFERENTIAL DIAGNOSIS 

deal in the night. After omitting the salicylates, which had been given 
steadily up to that time, the delirium cleared up within twelve hours. 
The knee-jerks were present, but the Achilles reflex absent. The eyes 
reacted better to accommodation than to light. The urine averaged 
60 ounces in twenty-four hours, the specific gravity varying very widely 
between 1009 and 1020. Hyaline and granular casts were numerous, and 
there was always pus in the sediment. The blood showed 12,800 leuko- 
cytes, 81 per cent, of which were polynu clear. 

On April 4th the swelling of the hands still continued. No obvious 
change in his condition accompanied the fever of April 10th to 19th. 

Purulent conjunctivitis was present throughout his stay in the 
hospital. The smear showed no gonococci; a variety of other organisms 
were present. May 1st he was discharged, not relieved. 

Discussion. — Judging from the condition of the pupils and of the 
ankle-jerks, there seems reason to believe that this patient has tabes, 
but evidently that is not his most important malady at the present time, 
so that our interest centers in the question : What else is the matter with 
him? We have obvious evidence that an infectious process has invaded 
the subcutaneous tissues, the joints, and the conjunctivae. In all prob- 
ability the pus in the kidney is to be attributed to a genito-urinary in- 
fection due to the same organism which is attacking his other tissues. 

At one period in the case it seemed as if the meninges, also, were in- 
fected, but the immediate cessation of meningeal symptoms when the 
salicylates were stopped makes it pretty clear that we were dealing with 
a salicylate delirium, which should always be borne in mind when any 
delirium occurs during the administration of salicylate in large doses. 
This is a very frequent occurrence. Indeed, it is impossible to avoid it 
if we are in the habit of pushing this drug rapidly to its physiologic limit, 
as we should do in most cases of acute arthritis. No considerable harm 
results, as the delirium always ceases promptly when the drug is with- 
drawn. 

We have evidence, then, of a very wide-spread infection of the body. 
Presumably this is due to one of the pus-forming organisms, since we 
have no definite evidence of tuberculosis, glanders, or syphilis. No 
further certainty can be arrived at without blood culture. 

Milder cases of this type are often called "inflammatory muscular 
rheumatism" (see above, p. 333), just as the milder septic infections 
of the joints pass as articular "rheumatism." But in both cases there 
is no reasonable doubt that we are dealing primarily with an infection 
of the blood-stream, following which the micro-organisms take root and 
multiply here or there, following laws of distribution which we do not 



PAIX IN THE LEGS AND FEET 365 

understand. Evidently the joints present especially favorable condi- 
tions for the growth and multiplication of micro-organisms. But we 
see many instances where an infection which seems to start in and to be 
distributed by the blood-stream gets its only recognizable localization 
in the heart, lung, kidney, or beneath the skin. I am inclined to think 
that the gall-bladder, the meninges, the peritoneal cavity, and possibly 
also the appendix, should be added to this list. I shall return to the fur- 
ther discussion of the types of pyogenic infection in the section on 
Fevers. 

Diagnosis. — General pyogenic infection. 

Case 187 

A clerk of forty-nine entered the hospital January 3, 1907. He 
had previously been in the hospital in 1889, with a diagnosis of acute 
rheumatism and mitral endocarditis. Since that time he has had many 
similar attacks. The attacks seem to be brought on by cold, indiscre- 
tions in diet, and alcoholic drink. He had syphilis in 1884, and later 
on had trouble in controlling the movements of the bowels, following an 
operation for piles and fever. 

At times he has been a heavy drinker. Ten days ago he "got cold" 
and passed bloody urine. Since then he has had several acute attacks 
of diarrhea. 

On examination his pupils are slightly irregular, but are equal and 
react normally. Marked pronation of both feet, with flattening of the 
arches, is noted. The second joint of the right big toe is immovable, 
thickened, not red or tender. There is some enlargement of the joints 
of the fingers and toes. X-ray shows thin, eroded areas on the fingers 
and toes, also some bony outgrowth. The urine shows nothing of note. 

Discussion. — What type of arthritis are we dealing with here? 
The association of the previous attack, in 1889, with a mitral endo- 
carditis gives us some ground for calling it a rheumatic arthritis, although 
we cannot be quite sure of the endocarditis, since there are no signs of it 
at present. It is impossible categorically to deny that a mitral endocardi- 
tis can heal, leaving no sign of its presence, but we have no good reason 
for believing so at the present time. Patients with true rheumatism 
often attribute their attacks to cold, but rarely to alcoholism or indis- 
cretions of diet. "I'll is feature of the history, as well as some Others 
tlv to be mentioned, does not fit the ordinary picture of rheumatic 
arthritis. 

Syphilitic disease; of the joints is not at the present time a very 

sharply defined clinical entity, but the cases on record have not been 



366 DIFFERENTIAL DIAGNOSIS 

characterized by such a tendency to recurrence and speedy recovery as 
have occurred in this patient. 

Since the arches of the patient's feet are markedly flattened, we must 
consider whether this deformity is a cause or result of his symptoms. 
The periodic and paroxysmal character of the patient's sufferings is not 
at all characteristic of mechanical weakening of the arch. Ordinary 
flat-foot is apt to cause pain until it is relieved by treatment. It does not 
appear and disappear so suddenly. Against flat-foot also is the presence 
of eroded areas and bony outgrowths, as shown in the .x-ray plate. 

But although flat-foot is very unlikely as a cause of this patient's 
troubles, it may well be viewed as a result of them, since almost any form 
of arthritis affecting the joints of the foot may be followed by flat-foot 
which remains as a cause of weakness and pain after the inflammatory 
trouble has passed. Thus it comes about that many cases of true ar- 
thritis of rheumatic or other origin are best treated, when they reach the 
doctor, by flat-foot plates and exercises designed to strengthen the ad- 
ductors of the foot. The inflammation has passed, and its sequel is 
mechanical weakening, not an infectious process. 

The #-ray evidence, the thickening and stiffening of the right big toe- 
joint, and the apparent relation of the symptoms to indiscretions in diet 
suggest gout. Nothing is said in the history of acute night-attacks of 
pain in the great toe, nor of the presence or absence of tophi. But 
further inquiry showed that both these gouty symptoms were present. 
Still unexplained is the relation between the gouty diathesis and the bony 
outgrowths seen in this and other cases of gout, as well as in the hyper- 
trophic form of arthritis. 

Outcome. — On the fourth of February the patient was discharged 
quite free from symptoms. Tophi were still present in his ears, and 
crystals of sodium biurate were obtained both in this attack and four 
years previously. 

Diagnosis. — Gout. 

Case 188 

A housewife of twenty-nine entered the hospital January 14, 1908. 
She was delivered of her first child on December 2d, but previous to that 
delivery she had much pain, owing, as she supposed, to a partially re- 
tained placenta. She was douched and cureted twice a day until she 
decided to get a new doctor. The second physician omitted the cureting. 
She has since been better. 

Two days after delivery both legs became swollen, and were still so 
when she was seen January 14th. On entering the hospital she com- 



PAIN IN THE LEGS AND FEET 



367 



plained bitterly of pain in the left buttock. Physical examination 
showed nothing but moderate jaundice and a bed-sore over the left sacro- 
iliac joint. The white count was 15,800; two days later, 38,200. On 
the second day after entrance she began to be delirious, and this con- 
tinued twenty-four hours, after which she was more rational, but had 
occasional hallucinations at night. There was marked dulness through- 
out the lower abdomen. The uterus was soft, flabby, 
and somewhat tender, but there was no vaginal dis- 
charge. 

By the sixteenth the edema had practically dis- 
appeared from the right leg, and was less in the left. 
A blood culture was taken, which showed no growth. 
Nevertheless, antistreptococcic serum was injected. 
The urine as drawn by catheter was bright green, but 
showed no other striking abnormalities. There was 
some tenderness in the left groin, but no other evidence 
of thrombosis. By the eighteenth this tenderness had 
increased and there was considerable fulness in the 
same resrion. 




Fig. 63. — Chart 
of case 188. 



Discussion. — Fever occurring after childbirth and 
accompanied by jaundice, by marked leukocytosis, and 
by pain in the left buttock and groin, points to the exis- 
tence of some deep-seated septic process originating in 
parturition. Though there is edema in both legs, we 
find no good evidence of peripheral thrombosis. Pelvic 
thrombosis possibly, or some other cause for pelvic obstruction to the 
circulation, is our natural conjecture, since all the other symptoms 
appear to originate in the pelvis. 1 

The green color of the urine is presumably due to biliverdin, a result 

— like the yellowing of the conjunctiva — of hemolysis. Nothing more 

definite can be said as to diagnosis. Pelvic sepsis we doubtless have; 

rm, extent, and origin can only be revealed by surgery orby the lapse 

of time. 

Outcome. — Incision allowed the escape of 25 ounces of pus, the 
which was extraperitoneal and apparently extended back to 
the region of the L< iliac joint. A culture showed streptococcus. 

patient died a v <•<■!. later. 

ecn postmortem the condition of the uterine and the periuterine 
tissues in the days soon after a normal labor 1 annol bul wonder li 

mt>oli< inf.in :i< »ns of the lung. 



3 68 



DIFFERENTIAL DIAGNOSIS 



Autopsy showed several fractures of the pelvic bones, deep burrow- 
ing pus without obvious point of origin, and streptococcus septicemia. 
The course of the temperature is seen in the accompanying chart. 
Diagnosis. — Fractured pelvis and sepsis. 

Case 189 

A medical student of thirty-three entered the hospital March 2, 1907. 
On February 21st his left great toe-joint swelled up, but the swelling 
was gone the next day. He then began to have pain and stiffness in 
the left hip. This has gradually increased ever since. Yesterday 
it took him twenty minutes to walk three blocks. 
No other joint has been affected. Any hip motion 
causes pain down the back of the leg. The great- 
est tenderness is over the tuberosity of the 
ischium. 

At the onset of his symptoms, hives appeared 
at night all over his body, some of the lesions 
being as large as half a dollar. They always dis- 
appeared in the day-time. For the past two 
days he has not had them. 

Physical examination was negative, except that 
all motions involving the hip- joint caused intense 
pain extending from the tuberosity of the ischium 
down the back of the leg. 

Rectal examination showed marked tender- 
ness on the right, but no mass or fluctuation. 
The case was considered an ischiorectal abscess by 
the surgeons. To an orthopedic consultant it 
appeared to be an infectious arthritis of the hip. 
The white count at entrance was 27,400, with 89 per cent, of poly- 
nuclear cells; on the fifth there were 15,000; on the twelfth, 9000. 
The course of the temperature is shown in the accompanying chart. 
By the tenth of March the pain and- tenderness were much less and 
the motions of the thigh freer. By the thirteenth he was almost free 
from symptoms and was able to walk about. X-ray was negative. Hot 
fomentations and sodium salicylate helped him very much in the early 
days of his illness. 

He was discharged on April 9th well. 

Discussion. — Pain and tenderness in the hip following a similar 
pain in the toe a week earlier are the presenting symptoms here. The 
hip pain has sciatic radiations, and is accompanied by fever and leuko- 























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PAIN IX THE LEGS AND FEET 



3 6 9 



cytosis. No source of infection is obvious. There has been no injury 
to account for the symptoms. 

Our first business is to examine the hip, sacro-iliac joint and spine. 
As a result of this search it seems that only the hip-joint is affected, 
the sciatic pain being doubtless secondary to this. What, then, is 
the infection of the hip? Tuberculosis, the commonest of hip infections, 
has rarely so acute an onset, and usually occurs in younger persons. 
The high white count, the hives, and the acute brief pyrexia seem more 
like some pyogenic infection. We have no positive evidence of gonorrhea 
or of any other infection from without. 

The marked tenderness over the tuberosity of the ischium and on 
rectal examination suggested a deep ischiorectal abscess, especially as 
the leukocyte count was so high. There is no way by which this diag- 
nosis can be excluded, though it is rare to see such an abscess clear up 
without breaking or being evacuated externally. It is a well-known 
fact that some cases of acute arthritis at the hip produce pain in the 
situations complained of by this patient. In view of these facts and 
of the favorable course of the disease without external manifestations 
of abscess it seems most probable that the case was one of acute 
arthritis of unknown origin, such as usually receives the name of 
"rheumatism." 

Diagnosis. — Acute infection of the hip. 

Case 190 

A widow of forty-five, with a negative family history, passed the 
menopause two years ago. She is a heavy drinker. Has been strong 
and well, but in the past two years has lost 36 pounds. She now weighs 
90 pounds. 

She has had a cough since last fall, with a grayish sputa. Has been 
unable to work for a year. In bed most of the last five weeks, because 
of pain in both legs and hips. Bowels move five or six times a day for 
the past six months. She entered the hospital August 15, igoi. 

urination.- Left pupil larger than the right, and reacts to light 
but not to accommodation. Ptosis of right eyelid. At left base behind 
and in the left axilla the breathing, vocal and tactile fremitus are dimin- 
ished, with slight dulness and many fine, crackling rales. 1 leart negative. 
Considerable tenderness in the whole belly. Dulness in the right 
kypochondrium and Bank, shifting slightly on change of position. 

elt bimanually in this region. It is movable anteroposterior^ 
and with respiration, and is apparently continuous with the liver. Navel 

Lower abdominal veins prominent. Slight edema of the belly- 
u 



37° 



DIFFERENTIAL DIAGNOSIS 



wall and of feet. Liver dulness reaches from the fifth space to four 
inches below the ribs. (See Fig. 66.) 

Temperature, ioi° to 103 ° F. (see Fig. 65). The white cells were 
5300. Urine negative. 

On the third day after entrance fluid was found in the belly. The 
Widal reaction was negative. On the sixth day she had three hemor- 
rhages — J pint each — from the bowel. 

Discussion. — The past history is of special importance in the 
interpretation of these symptoms. It is to be noted that a woman not 
previously subject to cough has now coughed steadily for nearly a year, 
and lost continually in weight, though she is at the menopause. As- 
sociated with her cough the chief symptoms have been 
diarrhea and leg pain. 

Summing up the physical examination, we may say 
that there are indications of very wide-spread lesions; 
the ptosis and pupillary changes indicate something 
wrong at the base of the brain. The lung signs must 
be interpreted (in the absence of cardiac or renal ab- 
normalities and in the presence of fever) as pleurisy 
with effusion or thickening. Finally, below the dia- 
phragm, there are evidences of pressure exerted ap- 
parently upon the vena cava and its radicles (as well 
as upon the spinal nerve-roots), by the mass figured in 
the diagram. The liver also seems to be much enlarged. 
Cancer, syphilis, or tuberculosis are the three diseases 
most capable of producing symptoms distributed through 
the body as widely as those in this case. Syphilis would 
account for the ptosis and pupillary changes. If we inter- 
preted the mass below the diaphragm as a syphilitic 
liver, the edema, ascites and fever would be explicable 
under the same hypothesis. The pleurisy and leg pains would remain 
unaccounted for, likewise the prolonged cough. The diarrhea might 
be due to amyloid disease of the intestine as a result of the syphilis. 

Malignant disease of the liver is sometimes associated with fever, 
and would explain the abdominal symptoms very well, but would not 
help us to account for the ocular signs, the chronic cough, the pleurisy, 
or the diarrhea. In the great majority of cases hepatic neoplasm is 
preceded by marked and long-continued gastric suffering, due to a 
preceding neoplasm of the stomach. We have no such suffering here. 
Tuberculosis involving the base of the brain, the pleura, the intes- 
tine, and peritoneum would account for all the facts in this case. Under 



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Fi^. 66. — Condition of the abdomen in Case 190; bedridden by pain in both legs. 



PAIX IX THE LEGS AND FEET 371 

this hypothesis the intestinal hemorrhages result from ulcerations of 
the gut, while the mass above the umbilicus represents a conglomera- 
tion of caseous glands and adherent intestinal coils. Enlargement of the 
liver might be due to fatty or amyloid metamorphosis. By strict reason- 
ing this diagnosis seems the most probable. 

Outcome. — The patient died August 18th. Autopsy showed ex- 
tensive tuberculosis of the mesenteric and retroperitoneal lymphatic 
glands, also of the large and small intestine, with ulcerations evidcntlv 
the source of hemorrhage. There were long-standing tuberculosis of 
both lungs and a general miliary infection. 

Diagnosis. — Tabes mesenterica. General tuberculosis. 

Case 191 

A housewife of thirty-seven entered the hospital October 18, 1907. 
Her family history, past history, and habits are good. For the past 
four and one-half years she has had frequent attacks of severe pain 
in the back of the left thigh, running down the leg, preceded often by 
a mild chill, and relieved after five or six hours of sweating. She is 
also troubled by nervousness and apprehension, and has worried a 
good deal since last winter about a prune-stone that she swallowed. 
She wonders where it is now. Her sleep and appetite are poor, and she 
has frequent attacks of headache and nausea, with some flatulence 
after eating and considerable constipation. 

Physical examination showed great restlessness; no swelling, tender- 
ness, or limitation of motion in any part of either leg. The arches of both 
feet were found to be much flattened. The rest of the examination, 
including the pelvis, the blood, and the urine, was negative. 

Discussion. — In view of the negative results of a searching physical 
examination and of general observation under hospital conditions, 
we seem driven to the diagnosis of a psychoneurosis with flat-foot and 
sciatica. Only by the continued study and prolonged observation of 
such cases can we realize the harm done by semiconscious fears based 
on such an incident as the swallowing of a prune stone. Especially in 
>ns who haw no knowledge of anatomy and physiology, the imagina- 
tion runs riot in speculation over the possible paths which such a stone 
might travel. Very great benefit follows in such cases if the patient 
can be assured, as a result of exhaustive physical examination, that no 
rue lesion exi 

An element in this benefit is the result of the patient's opportunity 
to bring to full consciousness, as the result of the physician's questions, 
the vague and unformed dreads from which he has been suffering. 



372 DIFFERENTIAL DIAGNOSIS 

As soon as they are forced to take shape, many of these apprehensions 
are alleviated, as the child's terror is gone when it has recounted its 
nightmare to its mother. To this familiar psychologic rule the name 
of the "cathartic method" has been given by Breuer and Freud. The 
essential point is that ideas or emotions which do the most harm to 
the body are often the most deeply hidden beneath the superficial 
layers of consciousness. The patient himself may be altogether unaware 
of their existence or may manifest his vague cognizance of them only 
by a systematic refusal to face them squarely, either in his own mind 
or in conversation with his physician. It is for this reason that the 
physician must sometimes employ what Freud calls " psycho-analysis" 
— the effort to find, by a persistent process of drawing the patient out, 
submerged ideas which resist more or less unconsciously the attempts 
to drag them to the surface. The process is risky, but occasionally 
valuable. 

Outcome. — After a week's rest and several long talks with her 
physician, counterirritation to the thigh, laxative medicines and proper 
shoes, she was discharged much relieved. 

Diagnosis. — Flat-foot; psychoneurosis. 

Case 192 

A cook of thirty-six entered the hospital March 14, 1907. At 
irregular intervals for five or six years she has had sharp pains in her 
arms and fingers, sometimes lasting as long as a week, usually worse 
in summer. During the last five years she has grown very stout, her 
average weight being 175 pounds. Otherwise her past history is good, 
likewise her family history and her habits. She was perfectly well 
until eight days ago, when she began to have pain in her heels, later 
passing around to the front of the foot, but never to the toes nor to the 
ankles. The pain kept her awake at night, and the foot has been 
swollen, red, and tender to touch. She has been in bed for the last three 
days, and seems to have been getting worse. 

The patient is 5 feet 4 inches tall, very obese; chest and abdomen 
are negative; reflexes normal; no tenderness over the joints of the feet. 
After a few days in bed the patient's pain was gone. There was no 
fever, and physical examination, including the blood and urine, was 
otherwise negative. 

Discussion. — This seems to be a case of obesity with pain in the 
feet; the nature of this pain it is our problem to discover. Is it of me- 
chanical or infectious origin? The redness, tenderness and swelling look 
like infection, but there is no fever or leukocytosis, no involvement of 



PAIX IX THE LEGS AND FEET 373 

any other joints, and experience has shown that even redness and 
swelling may result from the mechanical causes leading to the acuter 
forms of flat-foot. We are influenced especially toward the latter 
hypothesis when we find that there was no tenderness in the foot-joints, 
but only in the soft parts. The fact that she gets better as soon as she 
is off her feet is evidence pointing in the same direction. 

Very similar symptoms are often seen in gout, but I see no way of 
coming to any closer terms with this possibility, since we have no tophi, 
no night attacks of pain in the great toe, and no knowledge of a heredity 
or habit of life predisposing to gout. 

Outcome. — Padding the feet gave temporary relief. Much more 
permanent benefit followed the adjustment of flat-foot plates. 

This case well illustrates one of the indirect evils resulting from 
obesity. There are many cases of obesity which do not call for treat- 
ment by reason of the inconvenience or unsightliness of the fat, but 
which entail, nevertheless, a genuine risk to the patient. At any time 
the heart may be slightly weakened or the feet slightly strained by some 
temporary cause. In the obese the results of these otherwise trivial 
injuries may be a serious and obstinate illness. During this illness it 
is rarely wise to attack the obesity. Later, when the acute suffering is 
past, the patient may be unwilling to submit to the privations entailed 
by the attempt to reduce his fat. Thus many patients go on from bad 
to worse. Their good resolutions cannot be summoned at the right time. 

Diagnosis. — Acute foot-strain. 

Case 193 

A bartender of twenty-nine, with negative family history and past 
history, entered the hospital January 29, 1908; he has been in the 
habit of taking 25 glasses of beer a day, and one whisky every morning. 
For the past six months he has been growing short of breath, and lately 
has needed two or three pillows at night. He has no digestive symptoms, 
but rarely eats any breakfast. Five weeks ago he began to notice a 
swelling of his legs below the knee, accompanied by soreness and stiffness. 
The swelling disappeared after five days, but he continued to feel poorly 
and three weeks ago gave up work. Throughout his illness he has had 
slight cough and white, frothy sputum. Eight days ago lie began to have 
derable pain in both ankles and the left knee, without any swelling, 
redness, or fever. 

His pains have never been of a darting character. 

Hif lit is good. He has had DO headache. For the past 

eight days he has been in bed. 



374 



DIFFERENTIAL DIAGNOSIS 



As seen by the accompanying chart, the patient had a slight fever 
the first five days of his stay in the hospital. This was accompanied 
by a leukocytosis, which on January 29th reached 17,800; January 30th, 
18,800. The urine was sufficient in amount, averaging 1017 in specific 
gravity, w T ith a very slight trace of albumin, but no casts. His pupils 
reacted well to light and distance. The aortic second sound was mark- 
edly accentuated. The heart was otherwise normal, also the lungs. 

The pulse tension was apparently increased. 
The edge of the liver was felt one finger's 
breadth below the edge of the ribs, like- 
wise the spleen. There were considerable 
tremor of the fingers and obstinate insomnia. 
Within a few days he began to have pain 
in both arms, accompanied, as in the legs, 
by tenderness to pressure, although the 
reflexes were everywhere normal. 

Discussion. — Chronic alcoholism, six 
months' dyspnea and cough, and five weeks 
of leg pain are the essential data of the his- 
tory. Tabes is always to be thought of in 
men of these habits, but there is nothing in 
the physical examination to verify this con- 
jecture. Doubtless the great majority of 
such cases are destined to be labeled " rheu- 
matism," chiefly because they do not pre- 
sent a clear picture of any more definite 
malady. But there seems no good reason to fall back upon this ancient 
darkener of counsel when we have no fever and no special tenderness 
over the joints. 

Alcoholic neuritis is the natural explanation of diffuse leg pains 
occurring in an alcoholic without fever or evidence of local inflamma- 
tion. But in this as in most cases called alcoholic neuritis, we cannot 
answer the question, Why is this man stricken at this particular time; 
Why does the result appear so tardily when the cause has been busy 
throughout so many years? Doubtless there is some other determining 
factor of which we are, as yet, quite ignorant. 

Outcome. — The patient was given sodium bromid, 20 grains, after 
breakfast and dinner, and 30 grains at night. Twice he needed J grain 
morphin. For his cough he was given a prescription containing 3 
grains of codein, 15 minims of spirits of chloroform, 3 ounces of syrup 
of wild cherry. Of this mixture a dram was given every two hours 



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PAIN IX THE LEGS AND FEET 375 

when the cough was troublesome. On the first of February he was 
given 15 grains of sodium salicylate four times a day. By the ninth 
of February he was free from symptoms, but had slight toe-drop and 
slight tenderness in the calves. 

He was advised to avoid alcohol, and went home on the tenth of 
February. 

Diagnosis. — Alcoholic neuritis. 

Case 194 

A plasterer of thirty-seven entered the hospital June 12, 1907. 
He had his first attack of rheumatism at seventeen, when he was sick 
for several months. He has since then had five or six other attacks, 
and since his last attack, which lasted a month (five months ago), he 
has had a weak heart and more or less pain in various parts of his body. 
He has had urethral discharge off and on since he was seventeen, until 
five years ago; not since then. He takes from two to six glasses of beer 
and one or two whiskies a day. Two weeks ago he began to have pain 
and swelling in his feet and knees, and got transient relief from a Turkish 
bath. He has also had considerable severe pain in the region of his 
heart and right lower ribs for the past two weeks. He has had very 
little fever, but has sweated a great deal. For the past fortnight he 
has been troubled with many attacks of "hives," which, however, have 
not bothered him for the last two or three days. Throughout his illness 
be has had a cough, with whitish, frothy sputa. His appetite is poor. 
His bowels move twice a day. He has slept fairly well. The course 
of the temperature is seen in the accompanying chart. 

Examination. — The heart's apex was seen and felt in the fourth 
space, four inches from the midsternum in the nipple-line. There was 
no enlargement to the right. The sounds were regular and of good 
quality; the pulmonic second sound accentuated. A blowing, systolic 
murmur was heard best at the apex, very faintly over the rest of the 

ordia and in the axilla. The pulses showed nothing remarkable. 

The right lung was dull below the third rib in front and below the 

angle of the scapula behind. ( )ver this area distant bronchial breathing 

with Increased fremitus was detected. Just above the dull area, faint 

ling rale- were heard. The abdomen was negative. The right 

and shoulder, left shoulder and elbow , were slightly stiff and painful 

motion. 

No Sputum examined. The leul.oevte count w;is .'.'.000 at entrance, 
on the first of July, 12,000 on the third of July, and ranged low er 
■ that time. The urin< entially normal. 



376 DIFFERENTIAL DIAGNOSIS 

Discussion. — We can arrive at no clear conclusion, nor even at any 
helpful clue, from reading the first paragraph of this record. The 
patient has had many attacks of arthritis, some or all of which may 
have been due to gonorrhea, but it is not probable that his present 
joint pains are gonorrheal in origin, as he has had no local signs of 
that disease for five years. His other symptoms — cough, sweating, 
chest pain, urticaria, and anorexia — are very indefinite. Pleurisy is 
perhaps the possibility most indicated. 

On physical examination we find the evidence of multiple arthritis, 
of solidified lung (right lower lobe), and possibly of mitral regurgitation. 
All of these might be due to a single infectious agent, such as the pneu- 
mococcus or tubercle bacillus. So far as I know there is no good evidence 
that the gonococcus can produce pneumonia, although it might explain 
the other lesions from which the patient is suffering. The temperature 
chart (Fig. 68) is by no means characteristic of pneumococcus infec- 
tion, nor, indeed, of any other acute infection. It is more suggestive 
of tuberculosis. 

If we are to clear up the diagnosis any further our chief need seems 
to be a knowledge of the sputa, which should be repeatedly and care- 
fully examined. I have known tuberculous pneumonia to begin with 
just such a history and with very similar symptoms, including even 
the joint pains. On the other hand, many of the irregular, low-grade 
pneumonias, associated with a cardiac lesion and with some organism 
other than the pneumococcus, present a picture much like this. 

Outcome. — The patient was treated by tight chest swathe; 15 
grains sodium salicylate every four hours, chloroform liniment, an 
occasional dose of trional or morphin, and hot applications to the joints. 
On the seventh of July his only complaint was of weakness. At the 
right base there was still dulness, but the breathing and fremitus were 
diminished. These signs gradually disappeared, and he was discharged 
well on the seventh of August. 

Diagnosis. — Pneumococcus arthritis, endocarditis (?), and pneu- 
monia. 

Case 195 

A bartender of fifty entered the hospital March 24, 1908. Four 
weeks ago he had an attack of rheumatism in his feet, ankles, and in 
his shin, just above the ankles. The ankles were swollen, red and 
tender. He took 5 grains of aspirin every four hours on the fourth 
day of his trouble, and in a day or two his pain had gone, but ever since 
then he has been feeling mean and cannot sleep. He still has difficulty 



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",77 



PAIN IX THE LEGS AND FEET 379 

in walking, but can hop round fairly well. His appetite and bowels 
are normal. He gets up six or eight times at night to pass water, and 
thinks he passes more at night than during the day. (This observation 
was verified during his stay in the hospital.) 

There were various rose-colored macules scattered over the trunk. 
The pupils were found to be irregular, but reacted normally. 

Along the margin in each ear there were some white, firm nodules, 
the size of a pin's head, resembling sebaceous cysts, but surprisingly 
hard. The radials were tortuous; pulse of high tension; blood-pressure 
175: aortic second sound slightly accentuated. No cardiac enlargement 
could be demonstrated, and the heart showed no other abnormality. 
The breathing was slightly harsh in the left back, below the angle of 
the scapula; otherwise the lungs showed nothing abnormal. The 
abdomen was normal. There was flattening of the arches of both feet, 
especially the left; blood and urine were normal, except that the urine 
was persistently of low gravity, — ion, — with the slightest possible trace 
of albumin, but no casts. 

Discussion. — Arthritis, hypertension, nocturia, irregular pupils 
and flattened arches are the main points on which we may be clear 
from the start in this case. There seems good reason to believe that 
the patient's kidneys are somewhat atrophic, although no cardiac 
enlargement can be made out as a support for this hypothesis. The 
remaining question is: Does flat-foot account for all the rest of his 
symptoms, or is the weakening of his arches secondary to some form 
of arthritis? This brings us to the more careful consideration of the 
nodules on the patient's ears, for any case of doubtful joint lesion, 
especially in the feet, calls for a careful scrutiny of the aural cartilages. 
If the nodules on the ear were sebaceous cysts, they would be soft, 
never hard. Such multiple, firm white nodules along the ear margin 
may represent the sodium biurate deposits of gout. They may also 
occur when the ear has been frozen. The crucial test is to ascertain 
whether we can dig out of one of these nodules a chalky, gritty powder, 
showing fine, needle-like crystals under the microscope. In the present 
case we obtained such crystals and our diagnosis was made. 

Outcome. — He was given wine of colchicum root, 20 minims every 
four hours; veronal, 10 grains, for the first two nights; magnesium 
sulphate, \ ounce every morning. By the twenty-ninth his digestive 
disturbance was gone and he felt much better. The COlchicum seemed 
to produce diarrhea, and was promptly omitted. Thereafter he 
given a liberal diet, and by April 2d v as discharged, relieved. 

Diagnosis. Gout 



3^0 DIFFERENTIAL DIAGNOSIS 

Case 196 

A widow of fifty-five entered the hospital December 10, 1907. Her 
family history is good. Fifteen years ago she had cataract in both 
eyes, and was very successfully operated on, so that now she has very 
fair vision. As long as she can remember she has passed urine five or 
six times every night. She passed the menopause two years ago, without 
event. 

A year ago she began to have transitory numbness in the right hip 
and along the back of the right thigh. Six months ago she began to 
have a burning pain extending from the right knee to the right hip when- 
ever she remained seated for any length of time. She took osteopathic 
treatment during the summer, and was assured that her hip had been 
out of joint, but was now properly set. Nevertheless she did not improve. 
In July the pain was sharp, shooting, and often kept her awake. Since 
August it has been very bad until the first of December, since when it 
has been rather better. When the pain is severe, there is often involun- 
tary twitching of the foot and leg. This was more frequent six weeks 
ago than it is now. 

At present the leg feels fairly comfortable during the night and in 
the morning, but after she has been up for half an hour or so it begins 
to feel numb, and in a short time there is a burning and shooting pain 
which comes and goes through it. The back of the thigh and some- 
times the lower leg are markedly tender to touch. There has been no 
pain in the back, no eruption, no fever. She has been in bed or on a 
sofa most of the time for the last four months, and has lost about 25 
pounds in weight. 

The aortic second sound is louder than the pulmonic, and is preceded 
by a faint murmur transmitted up to the clavicle and down to the third 
space. Another murmur is heard with the first sound at the apex, 
but is not transmitted. In the lumbar and dorsal region there is con- 
siderable curvature of the spine with convexity to the left. The ribs 
to the left of the spine are prominent. The abdomen and all the deep 
reflexes normal. In the right groin there are glands somewhat larger 
than the average. There is tenderness along the right sciatic nerve 
and in the right calf. The patient is apparently more relieved by 
2 J 4 gr. of codein taken from her own bottle, of which she is very fond, 
than by larger doses of morphin and codein given her in the hospital. 
There seems to be a large mental element in her suffering. 

Discussion. — In seeking the origin of this pain it is natural to 
think first of the spinal curvature, which has forced the ribs apart on the 







.Fig. 69. — Outline of the mass referred to on p. 381. 




Fig, 70.— Ma-., apparently die cause of sciatic p 



PAIX IX THE LEGS AND FEET 38 1 

left and jammed them together on the right. But it is hard to see how 
this could produce suffering confined to the leg. Some of the intercostal 
nerves would probably be involved. 

We next consider the different varieties of arthritis involving the 
hip, spine or sacro-iliac joint. Infectious arthritis would hardly last 
so long. Osteo-arthritis would probably cause some pain in the back, 
and would be unlikely to be worse in the sitting posture. Further, 
the pain produced by it is hardly ever confined to the leg. X-ray ex- 
amination might help positively to exclude this disease. Sacro-iliac 
disease seems more probable. Against it, however, is the gradual 
onset, the age and sex, and the absence of any tenderness, pain or 
palpable abnormality in that joint. 

Some facts stated in the record incline us to believe that the pain 
may be of the functional or neurotic type. But before one settles down 
upon such a diagnosis or tries to content himself with calling the trouble 
a " primary sciatica " the pelvis should be thoroughly investigated for 
possible sources of pressure. The slight enlargement of the inguinal 
glands makes such an investigation all the more important. 

Outcome. — Vaginal examination showed in the right side of the pelvis 

a firm mass, tender on pressure, seemingly attached to the pelvic wall 

Fiu r . 69). The right thigh and calf were found to be § inch smaller 

than the left, but there was only slight weakness of the leg: no paralysis. 

Later, a large mass was found in the region of the right buttock 
(see Fig. 70). X-ray showed no definite abnormalities- On the 
second of January one of the glands was removed from the groin, and 
histological examination showed it to be malignant disease. 

On the fourteenth of January the patient was discharged somewhat 
relieved. 

Diagnosis. — Pelvic neoplasm. 

Case 197 

A colored scrub-woman of forty-nine, whose husband had previously 

been treated at the hospital for syphilis, but whose own family history, 

past history, and habits were not in any way remarkable, enter© 

wards December 26, 1907. Since February she has been graduall) 

running down, but worked until four days ago. During these mom lis 

she has .grown very weak and thin. Her meals have been Scanty and 

liar for some time, and once or twice a week she has vomiting 

, apparently without relation to the nature of her food. Since 

last winter she has been troubled by cold sensations in the left leg and 

constant aching there. For the last two or three months 



3 82 



DIFFERENTIAL DIAGNOSIS 



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she has limped, and occasionally she has been short of breath in going 
upstairs. 

The chest showed nothing abnormal. The edge of the liver was 
easily felt. The left knee-jerk could hardly be obtained, although the 
right one was easily brought out. The left Achilles jerk could not be 
obtained at all. The leg was quite warm to touch, although the patient 
complained of its being cold. Both legs could be extended more than 
normal upon the flexed thigh, without pain. There was no tenderness 
along the course of the sciatic nerve, but slight sensitiveness on firm 
ttesr _ _ , pressure over the left calf. An area 

of anesthesia was found, as shown 
in the accompanying diagram. Lift- 
ing the left leg with the knee stiff 
caused pain throughout the leg. 
Lifting the right leg produced no 
discomfort. 

Discussion. — Evidently we are 
dealing here with a neuritis involving 
the sciatic and probably other nerve- 
trunks. But as usual in such cases 
the diagnostician's chief task is to 
search for a cause for the neuritis. 
It seems probable that the patient 
has had syphilis, but syphilitic 
lesions so localized as to produce 
a neuritis confined to one extremity 
do not occur, so far as I am aware. 
Tuberculosis is so common in the negro race that it is natural to 
suspect it whenever a negro is seriously sick. But there seems to be 
no limitation of motion in any joint and no other evidence of muscular 
spasm, burrowing abscess, telescoping of joints, fever, or any other 
result of tuberculosis. The area of anesthesia and the long, steady 
duration of the pain make it more than ordinarily probable that we are 
dealing with a pressure neuritis, the position of which must be investi- 
gated by radioscopy and by pelvic examination. 

Outcome. — Inspection of the cervix uteri shows the cervical canal 
to be open, § inch in diameter and lined with small, projecting nodules. 
The patient has a slight uterine flow each day, but no foulness. The 
uterus extends half-way up to the navel. Lifting the straightened 
left leg causes moderate pain; lifting the right, no pain. 

January 7th a nodule was removed from the uterus, and shown by 




Pig. 71. — Shows anesthetic areas re- 
ferred to on p. 382. Complaints: Ach- 
ing and paresthesias (coldness) in left 
leg. 



PAIN IN THE LEGS AND FEET 383 

microscopic examination to be cancer. Presumably there were metas- 
tases in the broad ligament, causing pressure upon the pelvic nerves. 
Diagnosis. — Carcinoma uteri. 

Case 198 

A colored housewife of thirty-two entered the hospital June 7, 1908. 
Her family history and past history were excellent, her habits good. 
Since last fall she has had some pain and stiffness, without swelling, in 
the left knee. On February 13th she fell and injured the knee. Her 
physician said that she had sprained it. Since then there has been little 
swelling, but considerable pain. After three days in bed she got up and 
hobbled around with a crutch, the knee being somewhat stiff, but not 
painful, until two weeks ago, when pain and swelling commenced 
and have confined her altogether to bed for the last six days. During 
the last two weeks she has had occasional night-sweats and nose-bleeds. 
Her appetite is poor, and her bowels constipated. 

The chest and abdomen showed nothing abnormal. The reflexes 
were all present. The blood and urine were blameless; there was no fever. 
The left knee was found to be swollen and flexed to an angle of 70 
degrees. Its circumference was i\ inches greater than the right knee. 
Most of the swelling was on the anterior surface, and there was a sug- 
gestion of posterior subluxation of the lower leg. The skin over the 
knee was brownish, shiny, and slightly warmer than the right. There 
was some induration and some infiltration, with moderate tenderness on 
pressure. All attempts at motion caused extreme pain. 

Discussion. — Although there is much in the history pointing to 
a traumatic cause for this pain, the severity and long duration of the 
symptoms argue something more serious. 

Septic osteomyelitis has generally a more sudden onset, produces 
severer pain, disability and fever. This patient has had night-sweats, 
but, so far as we are aware, no fever. 

Tuberculous osteomyelitis might produce almost exactly this picture, 
though it would probably be accompanied by more fever and less pain. 
After so long a duration one would rather expect some sinus formation, 
but this does not always occur. Without #-ray evidence we cannot 
either affirm or exclude tuberculosis. 

Were there any evidence of spinal disease (tabes, syringomyelia), 
one might suspect a Charcot joint, though such joints are usually pain- 
less. But in this case there is no evidence of the primary disease whence 
Charcot's joint proceeds. 

Malignant disease of the bone — presumably sarcoma — would account 



3^4 



DIFFERENTIAL DIAGNOSIS 



for all the symptoms in the case. Between this and tuberculosis the diag* 
nosis must remain in doubt on the basis of the data here presented. 

Outcome. — X-ray examination showed extensive destruction of the 
lower end of the femur, with a fracture just above the condyles. June 
13th the leg was amputated for sarcoma of the femur. 

Diagnosis. — Sarcoma of the femur. 

Case 199 

A Russian tailoress of seventeen entered the hospital July 13, 1907. 
Six days ago her right knee and lower thigh became slightly swollen and 
very tender. Since then she has felt a little chilly, and has had a poor 
appetite, but no other symptoms of any kind. 

The course of the patient's temperature is 
shown in the accompanying chart. 

Physical examination of the internal viscera 
showed nothing abnormal. The right knee was 
red, very tender, slightly swollen. The white 
cells ranged between 8000 and 11,400. The 
urine was about normal in amount and in weight. 
There was no albumin, but a few hyaline and 
finely granular casts were found. Widal's reaction 
was negative. On the eighteenth the knee was 
less tender, but larger and the thigh was also 
swollen. 

Bier's treatment was given, one hour off, two 
hours on, night and day, without much relief. 

Discussion. — We are dealing with a mon- 
articular inflammation which has involved also 
the soft parts in the vicinity of the joint. Such a 
condition is never rheumatic, and the atrophic 
and hypertrophic varieties may also be excluded, because they are 
practically never confined in febrile cases to a single joint. 

Gonorrhea is perhaps the commonest cause of monarticular inflam- 
mation, but such infections are very rare in the young, unmarried Russian 
Jewesses of Boston. The patient had no vaginal discharge, and there 
was nothing else about her to make us suspect gonorrhea. Neverthe- 
less, this infection cannot be positively excluded. The course of the 
disease is too acute and too painful for tuberculous osteitis. 

To obtain any further light on the subject the joint should be as- 
pirated under aseptic precautions, as may be very easily done with an 
ordinary hypodermic needle. In my opinion joint puncture is far too 



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case 199. 



PAIN IX THE LEGS AND 1EET 585 

rarely performed. If done with rigid cleanliness, it has no dangers, 
produces scarcely any pain, and often gives us information of the highest 
value. Since I have been in the habit of using this procedure frequently 
I have been astonished to see how commonly one finds turbid or purulent 
exudates with demonstrable micrococci in joints which have been onlv 
moderately painful, and would certainly have been classed under or- 
dinary rheumatism but for the puncture. In some cases our treatment 
is made far more effective when the joint puncture makes it possible to 
prepare a vaccine from the invading organism. 

Outcome. — On the twentieth the right knee was aspirated and six 
ounces of fluid pus withdrawn. From this as well as from the circulat- 
ing blood a pure culture of the yellow staphylococcus was obtained. 
On the twenty-third the knee was surgically drained. Recovery followed, 
though there was limitation of motion in the knee. 

Diagnosis. — Septic knee. 

Case 200 

A waiter of twenty-four entered the hospital December 29, 1906. 
He had been in the hospital twice previously for exophthalmic goiter. 
The last time was in May, 1905. Since then he has worked steadily at 
hard jobs and has felt well. Four nights ago he came home with a pain 
in his left instep. The next day the pain extended up the leg, and in the 
afternoon was in both knees. It confined him to bed and took away 
his appetite. In October he weighed 150 pounds — a week ago, 130. 

Physical examination showed both eyes slightly prominent. The 
pulse ranged between 90 and 100. Examination was otherwise negative 
except for spasm of the leg muscles, both legs being held flexed. The 
patient insisted at first that they could not be moved, but was finally 
induced to straighten them out. Later, the right hand was held very 
stiffly, with the thumb flexed into the palm. The patient persisted that 
it too was paralyzed, but was finally persuaded that it was normal. 

Discussion. — The pain is probably due to muscular spasm, as in 
the familiar cramps most of us have experienced if the foot or Leg is bent 
in an unusual position. We can hardly doubt that these cramps are of 
the functional or hysteric type, in view of the results of moral suasion. 
but it is important to remember that a latent tuberculosis, recognizable 
only by .v-ray, may produce contractures of the legs fully as severe- ;is 
here dea ribed. If the contractures were not so wide spread, one 
might suspect flat foot with leg pains due to compensatory effort. The 

of the case reminds us distinctly of this lesion, but its later course 
makes this very unlikely. 






386 DIFFERENTIAL DIAGNOSIS 

The case illustrates the importance of firmness and confidence in our 
treatment — a confidence such as can be based only on the conviction built 
up in us by most painstaking physical examination and interrogation of 
the patient. Any doubt, vacillation, or hesitation in the management of 
such a case may lead to disastrous results. Decisive action, on the other 
hand, may be of incalculable benefit to the patient by nipping hysteric 
tendencies in the bud. Like so many other diseases, hysteria can be 
checked most often and most effectually in the incipient stages. 

Outcome. — A liberal diet with 30 grains of bromid every four hours 
for two days, preceded by an ounce of castor oil at the time of entrance, 
was followed by marked improvement. By the third of January the 
patient seemed practically well. He had still, however, a slight fine 
tremor of the hands, a remnant, no doubt, of his hyperthyroidism. 

Diagnosis. — Hysteria. 

Case 201 

A housewife of forty-four, who has had two miscarriages, one child 
of nine years and one of five, entered the hospital December 5, 1906. 
She herself was born with crooked legs, which were straightened by 
splints at her home in Sweden. She has had pneumonia four times. 

Nine years ago she had bad pains in her shoulders and arms, so 
that she could not raise her hands to her head. At that time lumps 
came out upon her arms, and ever since then she has had fleeting pains, 
now in one place, now in another. Thirteen days ago she was wakened 
out of sleep by pain in her feet. Now the pain comes suddenly and 
lasts from two to ten or more minutes, often shooting from the hips to the 
knees. It is almost as sharp as labor pain at times, and is accompanied 
by a dragging-down sensation. Her feet have been a little swollen. 
There has been some dyspnea on exertion and a little cough without 
sputa. She has attacks of rapid heart action almost every day. Five 
days ago she fainted, and had to sit up in bed all that night. Her 
appetite is poor, her bowels regular. There has been no nocturia. 

The patient was a neurotic-looking individual, and constantly 
demanded attention to trivial wants. The pupils were irregular, but 
reacted normally. The uvula was missing, and replaced by a white 
scar; the throat and lungs otherwise normal. The glands were palpable, 
but not enlarged, in the neck, axillae, and groins. Occasional squeaks 
were heard scattered through both lungs. The chest was otherwise 
negative; likewise the abdomen, blood, and urine. The shafts of both 
tibiae were enlarged and bowed forward, their surface rough and nodular. 
The deep reflexes were all present. 






PAIN IX THE LEGS AND FEET 3S7 

On both forearms, especially on the extensor surfaces, there were 
a dozen nodules from the size of a pea to half a horse-chestnut. They 
were oyster-shaped, discrete, of rubbery consistency, not tender, freely 
movable under the skin. Vaginal examination was negative. 

Discussion. — Fleeting pains in various parts of the body are often 
the most distressing symptom, and the earliest, in tabes dorsalis. The 
history of miscarriages and the tibial deformities increase the proba- 
bility of syphilis, and, therefore, of tabes. But this disease may be 
ruled out of consideration because of the fact that the pupils and the 
deep reflexes are normal. 

The patient's statement that her legs were crooked from birth 
makes us hesitate to attribute the present condition of the shins to 
syphilis, and as the patient has two healthy children, the miscarriages 
may well have had a non-syphilitic origin. But the scar in the soft 
palate and the absence of the uvula are decidedly more characteristic 
of syphilis, and in any patient who presents such lesions we must do our 
best to find any connection that may exist between the old infection 
and the present symptoms. Very possibly the vascular lesion so com- 
monly produced by syphilis may be connected with the pains here 
complained of. " Vascular crises " are certainly more common in those 
who have suffered a luetic infection, and through such crises, with or with- 
out a syphilitic neuritis, the pains of this patient might be accounted for. 

We must also consider, however, the nodules present upon the fore- 
arms and mentioned in the history as having appeared nine years earlier. 
The fact that these tumors have lasted so long makes it sure that they 
are not of a malignant type, and their limited distribution assures us 
that they are not connected with the much more widely distributed 
pain of which the patient complains. Their physical characteristics 
are those of lipomata, which are practically the only tumors which 
could last so long without more disastrous effects. 

Outcome. — The patient was given mercury and potassium iodid. 
Her leg pains were greatly relieved by injections of sterile water, especi- 
ally in the first two days after entrance. The lumps on the arms were 
taken to be fatty tumors. 

She was discharged much relieved on the twelfth of December. 

Diagnosis. — Syphilis. 

Case 202 

An engineer of forty-five entered the hospital July 25, 1906. His 

family history was negative. He had urethritis twenty years ago, also 

■ eeks ago, the latter attack followed by "rheumatism." He had 



388 DIFFERENTIAL DIAGNOSIS 

"slow fever" twenty years ago, and was five weeks in bed. Ten years 
ago he had inflammatory rheumatism, lasting three weeks, in both feet. 
No other parts were affected. He takes an occasional glass of beer, 
but denies any other use of alcohol. Eleven days ago his left foot 
became red, swollen, and tender. This gradually improved, but yester- 
day the right foot became similarly affected. He has been unable to 
work since the onset of the symptoms. He has had a poor appetite, 
constipation, slight headache and fever. 

The patient was obese, slightly cyanotic. The first sound at the 
apex of the heart was replaced by a short systolic murmur, not trans- 
mitted. The aortic second sound was accentuated, the heart not en- 
larged. The lungs were normal, likewise the abdomen, except for 
dulness in the right flank, which does not, however, shift with change 
of position. The second joint of the right toe was much swollen, hot, 
and tender. The same joint in the other foot was similarly affected, 
but the swelling also extended up the foot toward the ankle. 

Discussion. — In any patient who complains of subacute pain in 
both feet, and is not flat-footed, suspect gout. Most of the ordinary 
joint infections do not long remain confined to the feet, while gout is 
very prone to do so. 

Naturally, however, the first possibility to be investigated in this 
patient is gonorrhea, as he had so recently suffered from that infection. 

Next we must search the cartilages of the ears and nose, the great 
tendons near the elbow and ankle, and the vicinity of the great toe-joints 
for signs of uratic deposit. Thirdly, we must investigate the plantar 
arches, since precisely these symptoms might be produced by flat-foot. 
Other infectious and non-infectious lesions are far less probable. 

Outcome. — A smear from the urethra showed a biscuit-shaped 
diplococcus both within and without the leukocytes. It did not stain 
by Gram's method. The ears showed several small, yellowish-white, 
soft lumps. A scraping from one of these showed crystals correspond- 
ing to those of sodium biurate. X-ray showed areas of atrophy or 
erosion of the second phalanx of one great toe, which were believed by 
an #-ray expert to be due to gout. 

By the sixth of August the patient was practically comfortable. 
His treatment had consisted of sodium salicylate, 20 grains every hour 
for the first two days, then 10 grains every hour. Hot fomentations 
applied to the painful parts, an ounce of magnesium sulphate every 
morning, 10 grains of urotropin four times a day. He was not in bed 
after the twenty-ninth, and was discharged relieved on the sixth of 
August. 

Diagnosis. — Gout and gonorrhea. 



PAIN IN THE LEGS AND FEET 



389 



Case 203 

A restaurant-keeper of forty-nine entered the hospital September 
18, 1907. His mother died at seventy-two, after suffering from consump- 
tion for fifteen years. The patient has had " rheumatism " in his joints 
in two attacks of three weeks each — three years ago and eighteen months 
ago. He has had four attacks of urethritis, the last twenty-five years 
ago, but denies syphilis. 

He says that he was as strong as an ox until four years ago, when he 
sold his business and had difficulty in getting a new start. He then 
began to have almost constant pain near the right costal margin. These 
symptoms he has had off and on ever since. He has rather frequent 
attacks of vertigo and weakness, and his appetite is often poor. As 
long as he can remember his fin- 
gers have been clubbed, as they 
are at present. He usually takes 
two glasses of beer and two or 
three of whisky a day, and his use 
of tobacco is distinctly excessive. 
Yesterday he noticed that the 
corners of his mouth cracked. Off 
and on for four years he has felt 
feverish, and sometimes chilly and 
shivery in the evenings. His knees 
and ankles have burned, especially 
after he gets to bed. 

These joint symptoms have been 
getting steadily worse, and two 
days ago he had to give up and 
go to bed on account of pain in 
his legs and knees. Yesterday 
the right knee became a little 
better, the left worse. At the same time his left thumb began to be red, 
swollen, tender and painful. This time he had true chill. 

Physical examination showed that the left pupil was larger than the 
right, though both reacted normally. The heart was normal. There 
was slight dulness below the right scapula, with slight increase of vocal 
and tactile fremitus, and a few rales. Expiration was everywhere rough 
and prolonged. The abdomen was negative. The right knee was 
swollen, hot and shiny; the leg was kept bent at a right angle, and 
motion was painful. A similar condition was found in the right foot and 





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Fig. 73. — Chart of case 203. 



39° DIFFERENTIAL DIAGNOSIS 

ankle. Both feet were pronated. There was marked clubbing, cyanosis, 
and curvature in both planes in the ringers and thumbs, and to a less 
degree in the toes. Scattered over the chest and back was a reddish- 
brown, macular eruption, the spots about the size of the little finger-nail. 

Discussion. — There seems to be no way by which we can connect 
the mother's consumption or the patient's alcoholism with the present 
symptoms. The joints are obviously not tuberculous, and alcohol does 
not attack articular structures. 

Though it would be natural to connect the former attacks of ure- 
thritis with the present joint pains, the gap of twenty-five years between 
the two renders this impossible if the history is taken on its face value. 
In looking over the body for any other lesion which we can connect with 
the joint symptoms, we notice the irregular pupils, the clubbed-fingers, 
and the cutaneous eruption. 

If the clubbing of the fingers be assumed to be such as is described, 
it is not likely to have any connection with the arthritis. Bony out- 
growths near the finger-ends (Heberden's nodes) bear some resemblance 
to clubbed-fingers, but could hardly be mistaken for them. Such out- 
growths, if present, might incline us to conjecture that the right knee 
and ankle were the seat of a similar process. 

The irregular pupils and the cutaneous eruption look like syphilis, 
and since there is nothing very definite known about the differential 
symptomatology of syphilitic arthritis, it seems reasonable to interpret 
the joint manifestations in this case as syphilitic until this is disproved 
by therapeutic test. If no improvement follows the vigorous use of 
mercury and iodin, the joint should be tapped in search of some other 
infective agent. 

Outcome. — Under daily inunctions of mercury and the administra- 
tion of potassium iodid — 10 grains after each meal — the joints rapidly 
improved, and within ten days were practically well. 

The clubbing of the fingers remains in this, as in many other cases, 
a mystery. If clubbing were more carefully searched for as a matter of 
routine in cases presenting no pulmonary or cardiac lesions, it would 
be found, I believe, to occur in a great variety of diseased conditions and 
in a good many persons who have no demonstrable disease. Personally, 
I have observed it chiefly in chronic diseases of the liver (cirrhosis, ab- 
scess, gall-stone disease), in tuberculous peritonitis, and in ill-nourished 
children. 

Its occurrence in connection with long-standing cardiac disease (con- 
genital or acquired), with chronic pleurisy or empyema, phthisis and 
bronchiectasis, is, of course, familiar. 

Diagnosis. — Syphilis. 



PAIX IN THE LEGS AND FEET 



Case 204 



39i 



A plumber of thirty-seven entered the hospital April 11, 1908. He 
drinks and smokes to excess. Last evening he came home complaining 
of severe pain in both legs, especially in the left one. About one o'clock 
this morning he awoke unable to speak or to move the right arm and 
leg. Soon after the patient became unconscious, with stertorous breath- 
ing. 

The right forearm was in flexion, the fingers of the right hand flexed 
and spastic, the mouth drawn to the left; he made only inarticulate 
sounds. The right leg was spastic. By April 13th he had regained con- 
sciousness and he could move the toes slowly; otherwise he had no mus- 
cular control. His tongue came out to the right when protruded. There 
was no lead line. The chest and abdomen showed nothing abnormal. 
The blood-pressure was 155, the blood and urine normal, the right knee- 
jerk lively in comparison with the left knee-jerk. There were no other 
changes in the reflexes at this time. 

By April 15th Babinski's reflex had appeared in the right foot. 
Lumbar puncture was done on the seventeenth, and the cells in the fluid 
which was withdrawn were 50 to the cubic millimeter. Practically 
all of them were lymphocytes. 

Discussion. — The patient's occupation naturally leads us to attempt 
to explain the symptoms as a result of lead-poisoning, especially as 
paralysis and cerebral symptoms are present. But we do not expect 
pain or hemiplegia in plumbism, and we practically always find changes 
in the staining properties of the red blood-corpuscles. 

Against apoplexy, which, as the commonest cause of hemiplegia, 
naturally occurs to us next, is the patient's age, the very moderate 
blood-pressure, the absence of cardiac hypertrophy, and especially 
the results of lumbar puncture. 

The examination of the spinal fluid taken in connection with the 
absence of fever and the well-marked cerebral symptoms lead us straight 
to the diagnosis of cerebrospinal syphilis. A similar lymphocytosis 
occurs in the chronic forms of meningitis, especially tuberculous menin- 
gitis, but the clinical picture is quite different from that here under 
consideration. 

The most interesting point in this case is the occurrence of a pain 
which, though referred to the Legs, seems to be cerebral or spinal in origin. 
Such pains are seen not uncommonly in infantile paralysis, in some of 
the types of aeute myelitis and meningitis, and especially in cerebro- 
spinal syphilis. I recently studied a case in which attacks of Jack- 



39 2 



DIFFERENTIAL DIAGNOSIS 



sonian epilepsy, involving the right hand and forearm, were preceded, 
again and again, by severe pain referred to the parts about to be con- 
vulsed. Many of these central pains are preceded or accompanied by 
paresthesias. 

Outcome. — Under mercury and potassium iodid the patient was 
able to walk by the twenty-second, though his mind was still very sluggish. 
The next day he was sent to a State infirmary. 

Diagnosis. — Cerebrospinal syphilis (vascular crisis?). 

Case 205 

A machinist of thirty-nine entered the hospital May 29, 1908. His 
father died of apoplexy, his mother of dropsy. Seven years ago he was 
in bed five days, owing to swelling, redness and pain in the left knee. 





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Fig. 74. — Chart of case 205. 



In the past five years he has had tonsillitis six or eight times, once 
severely enough to keep him in bed. He had urethritis twenty-three 
years ago. 

He takes two or three glasses of whisky and two or three of beer each 
week. Two weeks ago he had a sudden chill accompanied by pain 
in the lower back, in the hands and the calves of his legs. He took to 
bed and has been there since, with persistent fever. The next morn- 
ing his right knee and the joints of the left hand were painful and stiff. 



PAIN IX THE LEGS AND FEET 393 

Six days ago the knee became red and swollen, while the left hand 
greatly improved. 

He has had no urinary symptoms; his appetite has been good; 
his bowels regular; there has been no sore throat and no cough. 
The course of the temperature may be seen in the accompanying chart. 

The chest and abdomen were negative, the knee-jerks normal; 
the plantar reflexes were not obtained. There was no glandular en- 
largement. The right knee was flexed at an angle of 45 degrees, any 
motion causing severe pain; all the evidences of fluid were found in the 
joint. 

Discussion. — As in many of the cases discussed in this section, 
we have here a general infection which shows, at first, no hint of its 
ultimate localization. 

Since the urethritis occurred too long ago for us to connect it with 
the present symptoms, it seems at first likely that the joint trouble 
may be due to the patient's repeated attacks of tonsillitis, and as gout 
and traumatism can be excluded by the lack of any evidence of them, 
tonsillitis would perhaps be the best guess we could make, were we 
debarred from any further and more direct investigations. But, as 
I have previously insisted, all monarticular infections of any serious- 
ness or obstinacy should be tapped, since the information thus to be 
derived may be of the greatest therapeutic value. (See p. 385.) 

In all probability the infecting organism is one of the pyogenic 
cocci, but it may be of great importance to know which, as a treatment 
by autogenous vaccines has much to recommend it. 

Outcome. — On the first of June the joint was aspirated and 35 cm. 
of fluid withdrawn. Specific gravity, 1008; albumin, 3.6 per cent.; 
in the sediment, 94 per cent, of the cells were polynuclear. Among 
them were numerous intracellular diplococci which did not stain by 
Gram's method. After this information had been obtained, the patient 
admitted a urethritis ten weeks ago, but insisted that there had been 
no discharge for the past four weeks. From the fluid withdrawn from 
the joint, gonococci were isolated in pure culture. From this a vaccine 
was prepared and injected. He improved quite rapidly after this, and 
by the sixteenth was able to go to the Zander room daily. 

On the twenty-fourth the knee was smaller and much more com- 
fortable. Bier's treatment was given after that date, and he was soon 
taught to apply it for himself. ( )n the fourth of July he was discharged, 
much relieved. 

Diagnosis.— Gonorrheal arthritis. 



394 DIFFERENTIAL DIAGNOSIS 



Case 206 



A metal worker of fifty entered the hospital March 27, 1908, stating 
that he had never been sick before, and giving a good account of his 
habits. Seven weeks ago, while at work,. he was taken with a sudden 
chill and went home and to bed. In the night he awoke with a sharp 
pain in the right shoulder and the left knee. He managed to get to 
sleep, however, and was much surprised to find the next morning that 
the pain had left the shoulder, but that the knee was hot and swollen, 
painful, red and tender. The knee has increased in size since, and 
he has been confined to bed, but has had no more fever or chills and 
no pain except in his knee. 

On physical examination the patient was very apprehensive and 
emaciated; there was a moderate, coarse tremor of the hands and feet; 
his face was dusky and dark under the eyes, his mucous membranes pale, 
though his leukocyte count was 80 per cent. His heart's apex was in 
the fifth space, an inch outside the nipple-line. The sounds were rapid 
and weak, the aortic second louder than the pulmonic second. There 
was no enlargement to the right and no murmur. The pulses were of 
very low tension, and the artery wall barely palpable. 

The lungs were negative; the abdomen showed considerable volun- 
tary spasm and slight dulness in the extreme flanks, not shifting on 
change of position. The left knee was markedly enlarged, tender, hot, 
red and very painful on motion. The swelling was most marked on 
the front of the knee, but extended up to the middle of the thigh 
and two inches below the tubercle of the tibia. The front of the 
thigh was fluctuant, tender, and covered by a tracery of prominent 
veins. A fluid wave could be transmitted from the knee to the middle 
of the thigh. 

Discussion. — This case, though very similar to the last, is given 
as an awful example of what may result from the neglect of early joint 
puncture in monarticular arthritis. It is a sin and a shame that this 
patient should have gone seven weeks without any effective etiologic 
or radical treatment. From the facts presented, no trained observer 
could doubt that there is pus in and around the joint. The nature of 
the infection is the only remaining diagnostic problem. 

Outcome. — On the twenty-seventh the knee was tapped and thick 
pus obtained. A culture from this pus showed streptococci. On 
March 28th the knee was opened and almost a quart of pus obtained, 
which apparently came from outside the knee-joint. The patient ran 
a jagged, septic temperature for a month, and developed a metastatic 






PAIN IN THE LEGS AND FEET 395 

abscess in the axilla, whence a colon bacillus was obtained. Despite 
amputation, he finally died. 
Diagnosis. — Sepsis. 

Case 207 

A physician forty-six years of age entered the hospital June 5, 1906. 
He had a primary lesion on his thumb one year ago; a secondary eruption 
with adenitis and sore mouth followed. A thorough antisyphilitic 
treatment has been given since. Two weeks ago a swelling appeared in 
the left foot. Within a few days the soles of both feet became red, 
swollen and tender. Ten days ago he was laid up in bed for three days. 
In every other way he is perfectly well. 

Physical examination showed considerable irregularity of the pupils, 
but was otherwise negative except as relates to the left foot, which was 
red, tender and slightly swollen over the dorsum and on the sole opposite 
the head of the second metatarsal bone. 

Discussion. — It is difficult to decide whether the syphilitic infection 
of a year ago has any connection with this patient's present suffering. 
It seems rather improbable, in view of the absence of specific lesions at 
the present time. 

As the patient has now no fever, one naturally thinks of flat-foot 
as a cause of such foot-pain, even though redness and tenderness would 
otherwise incline us to assume an inflammation. The mutual relations of 
arthritis and flat-foot have been previously discussed. (See p. 366.) 
In any such case the first and best thing to do is to try two therapeutic 
tests: (a) The effect of taking the patient off his feet, and (b) the effect 
of padding the arches. 

Outcome. — Though no medicine was given, the pain was entirely 
gone after a few days' rest, and as soon as foot-plates had been fitted, the 
patient was able to walk without pain. 

We have still on our hands, however, the question: Why did the 
arches break down just at this time? Possibly some latent and un- 
prized phase of his old syphilis may provide the answer. 

Diagnosis. — Flat-foot. 

Case 208 

A laborer of forty seven entered the hospital July 6, 1906, complain- 
ing of sciatica. He had a similar trouble nine years ago, which lasted 

three weeks. Otherwise he has been well until sewn months ago, when 

radually began to notice pain in the back and left hip, running 
the left thigh behind and extending into the calf. He has had tc 

give up work, but has walked about with a marked limp. 



396 DIFFERENTIAL DIAGNOSIS 

For the last six weeks the pain has been much worse and has kept him 
awake at night. He has had some tingling and other curious sensations 
in his lower left leg. He has lost 15 pounds in weight, though his appe- 
tite is good. 

Physical examination shows that the patient cannot stand erect, 
but supports himself with the spine curved to the left and forward. The 
motions of the back are inhibited by a pain referred to the sacro-iliac 
joint. Full extension or flexion of the left leg is impossible on account 
of pain referred to the same point. There is tenderness over the 
region of the left^ sciatic nerve and slight atrophy of the muscles of the 
left leg, making about one inch difference in the circumference of the 
thighs and calves. 

Discussion. — In the out-patient records of the Massachusetts 
General Hospital previous to the year 1900 there are to be found notes of 
a large number of cases with the diagnosis "lumbago and sciatica." 
At the time when we were dealing with these cases it always seemed 
remarkable to me, and I imagine also to many of my colleagues, that a 
disease affecting a muscle (lumbago) should occur simultaneously with 
a neuritis (sciatica) . The case reported above is typical of a great many 
of those which we used to label "lumbago and sciatica." 

Looking at it from the point of view of the present day, one would 
say, first of all, that the lumbar pain has lasted too long for lumbago, 
which, like other muscular pains, is a transient though perhaps recur- 
rent affair, producing its symptoms for not more than a week or two at a 
time. 

The other half of the old diagnosis — sciatica — we should now be 
unwilling to make without a far more searching investigation of the 
possible causes for sciatic pain, especially diabetes, disease of the lumbar 
spine or sacro-iliac joint, and pelvic tumors. 

The present case is fairly typical of what is now called sacro-iliac 
strain, a diagnosis based most firmly upon the therapeutic test — the 
means by which it is relieved. The etiology and pathology of the affec- 
tion are still very obscure, and the theories usually advanced do not 
seem satisfactory to me. 

Outcome. — The patient was seen by Dr. Goldthwait, who made a 
diagnosis of "chronic strain" of the left sacro-iliac joint. 

The pain was entirely relieved by a pillow under the knee and a folded 
sheet under the lumbar spine, with rest in bed. A plaster jacket was 
then applied, and by August 2d he was free from pain and could walk a 
little. On that day he was discharged, much relieved. 

Diagnosis. — Sacro-iliac strain. 



PAIX IN THE LEGS AND FEET 



397 



Case 209 



A housemaid of twenty-five entered the hospital August 16, 1907, 
stating that for three weeks she had had swelling, pain and tenderness 
in the lower legs, especially at night. 

Physical examination shows yellowish pallor and only 25 per cent, 
of hemoglobin; the white cells varied between 28,000 and 43,000 in the 
course of the next four days, the polynuclears making up 82 per cent, 
of this increase. For temperature see the accompanying chart. 

Physical examination was negative save for an indefinite resistance 
in the right upper quadrant of the abdomen. The front of both legs 
showed numerous sharply defined, punched-out ulcerations on a red- 
dened base; the right lower leg showed soft nodules the size of a pea, 
raised one-half inch above the surround- 
ing skin, covered with unbroken skin. 
They were of a doughy consistence and 
tender. 

The subcutaneous ulcerations were 
drained by surgical incisions and con- 
siderable pus liberated. 

Discussion. — Obviously, we are 
dealing with some type of acute infec- 
tion, the most probable source for 
which seems, at first examination, to 
be the gall-bladder. But on further 
scrutiny it is equally obvious that we 
need some source for the very marked 
and apparently chronic anemia which 
has reduced the hemoglobin to 25 per 
cent. 1 In cases accompanied by 
marked secondary anemia I have found 
that in moving toward a diagnosis it 
is a useful strategic maneuver to fix 

attention, first of all, upon this anemia, and to investigate what causes 
of such an anemia are possible in this patient. The patient may, of 
* . be chlorotic, but as she certainly has something else the matter 
with her, we must make two diagnoses (which we are always loth to 
do in case we call it chlorosis. 



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1 I regret thai no estimation of red <<-lls was recorded in this case. Ii was evident, 
■ r, from th»- appearance of tin- stained smear, thai thej wen- not greatly reduced 

pe. 



398 



DIFFERENTIAL DIAGNOSIS 



Aside from chlorosis, what are the possible causes of a severe secon- 
dary anemia in a woman of twenty-five who has had no hemorrhage, 
no malaria, and no evidences of malignant disease? The lesions on 
the shins, and especially those covered with unbroken skin, suggest 
gummata, and although there is certainly a secondary infection, the 
hypothesis of syphilis should be put to the therapeutic test. 

Outcome. — Microscopic examination of an excised nodule showed 
gumma with secondary infection. The lesions quickly cleared up 
under antisyphilitic treatment. 

Diagnosis. — Syphilitic periostitis. 

Case 210 

A hostler of thirty-two was first seen June 3, 1907. He takes five 

or six beers and three or four whiskies daily, but denies venereal disease. 

Yesterday morning he woke with a chill followed by headache, fever 

and aching bones. To-day his chief com- 
plaint is of pain in his legs. 

Physical examination of the chest and ab- 
domen is negative. The right tibia is rough 
and nodular; the skin bluish red and con- 
taining three ulcerated areas from the size of 
a silver dollar to that of the palm. The course 
of the temperature and pulse is seen in the 
accompanying chart. The leukocytes are 
12,500. The glands in the right groin are 
enlarged; urine normal. X-ray shows evi- 
dences of a syphilitic periostitis. Under large 
doses of iodid of potash, the glands of the 
groin became smaller and the pain disappeared 
within ten days. 

Discussion. — This case is introduced 
chiefly to show the importance of #-ray ex- 
amination of the shin bones in all cases in- 
volving an obscure pain referred to the lower 

leg. Without the evidence thus obtained a diagnosis would here have 

been impossible. 

Doubtless there was also a certain degree of secondary infection 

in the ulcerated area, whence the chill, high fever and other acute 

symptoms may be explained. 

Diagnosis. — Syphilitic periostitis. 



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210. 



PAIN IN THE LEGS AND FEET 



199 



Case 211 

A shoemaker of nineteen entered the hospital May 14, 1908, with 
a good family history, past history and habits. Three days ago lie 
began to have pain in his legs and to a lesser extent in his left side. At 
night he vomited twice and has since kept his bed. The pain has been 
more severe in his chest, until to-day, when it has diminished. He 
has slept and eaten poorly and has been constipated. He has had no 
cough and no chill. 

Physical examination showed dulness in the lower half of the left 
back, with bronchial breathing; increased voice and fine, crackling rales. 

The leukocytes were 22,000. The urine and the 
rest of the physical examination were normal. The 
course of the temperature is shown in the accom- 
panying chart. A tight swathe prevented all pain. 
On the nineteenth he was put in a chair, and by 
the twenty-fifth was able to go to his home. 
Throughout his illness he had practically no cough 
or expectoration. 

Discussion. — This case is introduced in order 
briefly to exemplify a pain due to general infection, 
but confined to the legs. Some of these pains are 
very mysterious, and give not the slightest indica- 
tion, during the first two or three days of the pa- 
tient's sufferings, where the trouble is finally to settle. 
Obviously, in the present case the pain was ushering 
in a pneumonia. I recently saw a woman who suffered 
for two days from quite intense pain throughout all 
the tissues of the thighs and legs. We could find 
absolutely no cause for it, though the presence 
of an accompanying fever and leukocytosis made us believe that some 
infective agent was at work. The joints, the nerves, the muscles and 
subcutaneous tissues, the arteries and veins were searched for evidence 
of a cause for the pain, but none was found. On the third day an acute 
dysentery made its appearance, and the pain in the- legs quickly dis- 
appeared. 

In view of these and similar cases we must always bear in mind, when 
examining the legs for a cause of pain referred to them, that a genera] 
unlegalized Infection bearing no special relation to the leg may have 

invaded the body. Disease of the brain or spinal cord should also be 

mbered as among the long range causes for leg pains. 
Diagnosis. Pneumonia. 







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400 DIFFERENTIAL DIAGNOSIS 

Case 212 

A homeopathic confrere called me in consultation October 31st to 
see a curious case of grip with pelvic neuralgia and perhaps malaria. 

The patient was a young architect of twenty-seven, always pre- 
viously well until he began, October 1st, to have what he called "grip" 
— i. e., a fever of 103. 6° F., accompanied by aching in his head, back, 
and legs. After a couple of days the temperature fell to 101 F., and 
the patient had what was called a right facial neuralgia. From October 
5th to October 12th the temperature did not rise above ioo° F., and 
the patient seems to be convalescent, though complaining somewhat 
of piles. He then went off for a week's vacation, but on his return, 
October 19th, said that he had been poorly while he was away, suffering 
a great deal from pain in the testes, which was especially severe every 
night about 6 p.m., and was associated either with a rectal tenesmus, 
a urinary frequency, or both. The pain radiated to both hips and groins. 

On October 25th the temperature was again 101 ° F., and since that 
time it has risen to that point or a degree higher every day. On the 
twenty-seventh, quinin, the doctor said, seemed to stop the pelvic neu- 
ralgia, but for the last two days he has been eating poorly, and at 11 p.m. 
to-day his temperature was 103 ° F. and the pelvic pains so great as to 
require morphin. The urine has been high colored, but not cloudy, and 
shows no gross sediment. The blood has not been examined. 

Physical examination of the chest was negative; the spleen was not 
enlarged, and the blood showed no malarial organisms. There was 
no evidence of an influenzal infection of the upper air-passages or else- 
where. The urine was high colored, but showed no other important 
abnormality. The leukocytes numbered 28,000, 83 per cent, of which 
were polynuclear. 

The local examination, which had been hitherto neglected, showed 
a reddened, tender, and resistant area close to the rectum on the left. 

Discussion. — The points of interest in this case are the slow " set- 
tling" of the infection at the point where it was finally discovered, 
and the unwisdom of treating symptoms without careful physical 
examination. In view of the local conditions one could hardly doubt 
that the patient was suffering from an abscess near the rectum, the 
wide radiations of the pain being due, doubtless, to the burrowings of 
pus which should have been liberated long before. 

Incision allowed the escape of a pint and a half of pus. The abscess 
cavity healed up in the course of three weeks, and by December 1st 
the patient was back at work. 

Diagnosis. — Ischiorectal abscess. 



CHAPTER XIII 

FEVERS 

The distinction between "long" and " short" fevers — i. e., those 
continued for two weeks or more, and those of briefer span — allows 
us to narrow the diagnostic possibilities of the "long" group practically 
to three alternatives: tuberculosis, sepsis, typhoid. 

In the following table l I have classified 784 cases in which a fever 
lasted two weeks or more without touching normal: 

Typhoid 586 

Sepsis 70 

Tuberculosis 54 710 (90 per cent.) 

Meningitis 27 

"Influenza" 10 

Acute "rheumatism'' 9 

Leukemia 5 

Cancer 4 

Syphilis 2 

Trichiniasis 2 

Cirrhosis 2 

Gonorrhea 2 

"Scattering'' 11 74 (10 per cent.) 

" "784 

It will be noted that most of the 10 per cent, of long fevers not due to 
typhoid, tuberculosis or sepsis are due to diseases easy of diagnosis 
because of their local or distinctive signs. Thus meningitis, with its 
evidences of cerebrospinal irritation, "rheumatism" with its joint 
lesions, leukemia and trichiniasis with their blood changes, cancer 
with the easily palpable tumors which febrile cases practically always 
show, gonorrhea and cirrhosis with their characteristic local manifesta- 
tions — all these are, or should be, easily recognized. Obscure long- 
continued fevers, then, will include only the dominant three, plus "in- 
fluenza" and syphilis. In this group the dominant three make up 
98 per cent. 

Instead of "influenza" we should write "unknown infection" against 
most of the 1.2 per cent, of obscure fevers so diagnosed in my statis- 

1 R. C. Cabot, The Three Long-continued Fevers of New England, Boston fcledical 
ami Surgical Journal, August 29, 1007. 

M 101 



4Q2 DIFFERENTIAL DIAGNOSIS 

tics, for bacteriologic proof of influenza was rarely obtained in this 
series. I do not doubt that long as well as short fevers may be pro- 
duced by true influenzal infection, but I believe that the diagnosis is 
rarely well founded on cultural evidence. 

The proportion of typhoid in the figures above quoted is far too 
high, because in the Massachusetts General Hospital, whence these 
figures were gathered, the typhoid cases of a large area are aggregated. 
In fact, the number of long typhoid fevers is generally far less than 
the number of long tuberculosis or septic fevers; but these are treated 
at home and therefore missed in hospital statistics. 

The manifold manifestations of tuberculosis — in the spine, the hip. 
sacro-iliac, and other joints, in the lymph-nodes, peritoneum, meninges, 
and genito-urinary tract, as well as in the lungs and pleura — may all pro- 
duce long as well as short periods of fever. 

Under "sepsis" I mean to include here an extensive variety of 
clinical pictures, such as — (a) vegetative endocarditis (also called 
benign, malignant, ulcerative, or septic); (b) puerperal fevers; (c) 
deep-seated abscesses originating in the appendix, the gall-bladder, 
the genito-urinary tract, the stomach, and duodenum; (d) empyema; 
(e) wound sepsis; (J) lymphangitis, erysipelas, and phlegmonous in- 
flammation. 

Yet only a small minority either of tuberculous or of septic fevers 
are obscure in origin or lead us to any diagnostic puzzles. The osseous, 
lymphatic, peritoneal, and meningeal forms of the disease are usually 
easy of recognition. It is chiefly the pulmonary and renal forms of 
tuberculosis that are latent and produce obscure fevers. Among the 
fevers due to sepsis also the great majority are plain enough. It is 
chiefly in the cases of vegetative endocarditis, and in some of the deep- 
seated abscesses — especially those in or about the liver and kidney — 
that local symptoms are absent. 

Hence we may say that, when studying obscure fevers of long dura- 
tion, we should search especially for: 

(a) Pulmonary and renal tuberculosis. 

(b) Typhoid. 

(c) Hepatic, subphrenic, renal, or perirenal suppurations. 

(d) Vegetative endocarditis. 

The lung, the liver, the kidney, and the blood are especially to be 
suspected and examined. Auscultation, rr-ray examination, blood- 
counts, cultures, biologic tests, cystoscopy and a carefully taken history 
will help us most in difficult cases. 






Causes of Long Fevers 



1. TYPHOID 

2. SEPSIS 

3. TUBERCULOSIS 

4. MENINGITIS 

5. INFLUENZA 



6. INFECTIOUS 
ARTHRITIS 



7. LEUKEMIA 

8. CANCER 

9. SYPHILIS 

10. CIRRHOSIS 

11. GONORRHEA 

12. "SCATTERING" 



1172 

140 

108 1 

54 

20 

18 

10 
8 
4 
4 
4 

26 



1 In statistics of hospitals for chronic diseases this figure is often much larger pro- 
portionally. 



vk 



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Causes of Short Fevers 

(Omitting those listed under " Long Fevers " and excluding the 
exanthemata and diphtheria.) 



1. "COMMON COLDS," HHI^^^HHlH^HB^^HHaHHHHl 4164 
Including : 



(a) ACUTE "> 

bronchitis/ 

(b) ACUTE 1 

tonsillitis/ 

(c) ACUTE -) 

pharyngitis/ 



1620 

t405 

751 



(d) ACUTE 1 

"INFLUENZA"/ 

2. ACUTE APPENDICITIS MMHHHH 1504 

3. ACUTE ARTHRITIS ■■I^HH *016 

4. SALPINGITIS MMHMi 871 

5. PNEUMONIA ■■■§■ 803 

6. LYMPHANGITIS ■■ 365 

7. SINUSITIS flU 259 

8. ERYSIPELAS Hi 241 

9. POLIOMYELITIS ■■ 227 



404 



FEVERS 405 

SHORT FEVERS 

Excluding the exanthemata and the milder types of the infections 
just mentioned, we may say, I think, that the majority of short fevers 
are of unknown origin. The habit of attributing such fevers to "com- 
mon colds," to "grip," "influenza," "febricula," "auto-intoxication," 
"rheumatism," constipation, etc., is a pernicious way of concealing 
our ignorance not only from our patients, but from ourselves. 

The temperature-pulse ratio has never seemed to me of much prac- 
tical value in diagnosis. It may confirm a diagnosis established mainly 
in other ways, but in my experience it is as apt to lead us wrong as 
right. In typhoid the pulse may be relatively slower than in fever of 
similar degree due to pneumonia, sepsis or tuberculosis, but there are 
many exceptions to this rule. 

The rapidity of respiration is also a very unreliable guide. Many 
non -respiratory, infections (e, g., typhoid, erysipelas, liver abscess) 
may notably quicken the respiration, while the sudden fall of respira- 
tion at the crisis in pneumonia, when the lung signs remain quite un- 
changed, inclines us to believe that even in pneumonia the polypnea 
is due to the general rather than to the local pulmonary condition. 

NON-INFECTIOUS FEVERS 

(a) Brain injuries and diseases of any kind may produce fever of 
various types. Thus cerebral hemorrhage, tumor, and acute delirium 
due to alcohol or other causes, often raise the temperature considerably. 

Other important causes are: 

(b) Malignant tumors (such as cancer of the liver, Hodgkin's disease), 
especially when extensive and of rapid growth. 

(c) Leukemia and all types of severe anemia. 

{d) Poisoning by belladonna and illuminating gas. 

(e) Uremia, eclampsia, hepatic toxemia, gout, and hyperthyroidism 
(Graves' disease). 

if) Sunstroke. 

Whether pure "nervousness" or hysteric states of ODe or another 
type can produce fever is a question which frequently arises. 

Pyrexia not exceeding ioo° F. and of short duration certainly accom- 
panies many such psychoses. Temperatures taken when a patient 
first enters a hospital often register io.?°, 103 , or 104° F., but are 
followed by normal records within twelve to twenty-four hours. Ex- 
haustion and alarm doubtless contribute to produce these temporary 
abnormalities. Aside from the two types of U-wv just mentioned, 1 
> experience of pyrexias due to psychic caua 



406 DIFFERENTIAL DIAGNOSIS 



Case 213 



A fourteen-months-old girl baby was seen December 23, 1902. She 
was born in Cuba, had malaria before she left the island, and since she 
came to live in Cambridge, Mass., had, during the summer just past, a 
large number of mosquito-bites. November 16th the baby began to 
vomit, lost appetite and soon became weak and listless. She was fed 
on Eskay's food and milk. From that time on she ran a continuous 
fever, ranging from 100.6 to 104 F., with long excursions almost every 
day. She was fretful and listless, dozing most of the time, rolling her 
head back and forth upon the pillow, running her tongue repeatedly over 
the region of the expected incisor teeth, but exhibiting no more definite 
localizing symptoms. 

The symptoms were ascribed to teething, but the child grew steadily 
worse, and by December 2d voluntary motion of the extremities had 
almost altogether ceased. Repeated physical examinations elicited 
nothing either in the legs or elsewhere. December 3d the child seemed 
to be markedly "anemic," and it was difficult to obtain blood from the 
toe. Nevertheless, the hemoglobin was 80 per cent. The Widal reac- 
tion was negative; the white cells, 6500. Iodophilia was very marked. 
The child was seen by Dr. C. P. Putnam daily for a week, but no diag- 
nosis was made. 

December 6th a squint was noticed. This disappeared within 
twenty-four hours and has not recurred since. December 23d, the fever 
continuing unabated, while the child grew constantly thinner, I saw her 
in consultation, but could make no diagnosis. The blood showed at 
this time: 

Red cells, 4,892,000; white cells, 39,000; hemoglobin, 80 per cent.; 
iodophilia, very marked; among the leukocytes, 93.6 per cent, were poly- 
nuclear. 

A week later Dr. T. M. Rotch saw the baby, noticed a slight "rosary," 
made a diagnosis of rickets, and directed the treatment accordingly. 
Nevertheless the child continued to go down-hill. 

Discussion. — As in the case previously mentioned, there was no 
culture made from the urine, and the possibility of urinary infection 
was not, so far as I know, considered. One heard nothing of such 
infections in 1902. The ears were examined, with negative result. 

As the child had been healthy at birth, had been properly fed during 
most of its life, and showed no more signs of rickets than a large propor- 
tion of healthy children, there seemed to me no good reason to attribute 
its serious and progressive symptoms to that disease. 




Fig. 78. — Condition of the spleen and liver in Case 214. 



FEVERS 



407 



Outcome. — January 23d the child died. Autopsy by Dr. W. T. 
Councilman showed in the kidneys numerous foci of hemorrhage 
between the tubules; also here and there infiltrations of leukocytes, so 
extensive as to constitute small abscesses with destruction of the tubules 
and epithelium. Organisms of the colon group were found in these 
lesions. 

At the time when this baby's illness occurred the frequency and import- 
ance of the urinary infections of girl babies was not recognized. Natur- 
ally, therefore, no one thought of this diagnosis during the life of the child, 
though in all probability this life might have been saved had the urinary 
tract been investigated earlier. 

Diagnosis. — Renal infection (bacillus coli). 

Case 214 

A real-estate broker of thirty-nine was seen June 19, 1909. He had 
11 typhoid " when he was six, and again when he was twenty-one. For 
the ten years succeeding this attack he had gall-stone colic in frequent 
paroxysms, which were finally cured by an osteopath in 1900. He had 
no fever at that time. His wife died in 1900. He married again in 1908. 

February 24, 1909, he went to Alabama feeling perfectly well. About 
six weeks ago he lost his appetite and began to have a headache, with 
much pulsation in his head. Soon after he noticed that climbing a slight 
hill exhausted him completely. For the past thirty-three days he had 
been aware that he had fever, ranging between 99 and 103 ° F., and 
usually reaching the lower figure once or more in every forty-eight hours. 
With this fever he had repeated chills and lost fifteen pounds. 

He returned from the south a month ago, and has been in bed for 
ten days, troubled a good deal with gas in his bowels, with occasional belly 
pain and much weakness. Some weeks ago a homeopathic pathologist 
found a malarial parasite in his blood, and since then he has received at 
least 20 grains of quinin a day. Nevertheless, he has continued to have 
fever and has grown steadily paler, thinner and weaker. 

On physical examination he shows a yellowish pallor, hemoglobin 
being 55 per cent. The conjunctivae are not discolored; the urine shows 
no bile-pigment. The chest and extremities are negative, the abdomen 
as per diagram (Fig. 78). The ^\^ of the spleen and liver are both 
Very sharp and hard; the surface of the liver seems to be somewhat 
irregular. There is no ascites. 

Discussion. — As will be at once surmised from the treatment referred 
to above, malaria was the diagnosis up to June igth. The chills, the 
anemia, the large, hard spleen and the report of malaria] parasites in the 



408 DIFFERENTIAL DIAGNOSIS 

blood had led very naturally to this diagnosis. Yet in my opinion malaria 
could be absolutely excluded, owing to the fact that the fever, though 
approaching the tertian type more nearly than any other, did not yield 
appreciably to large doses of quinin, which were obviously absorbed, 
as the patient's ears had been ringing steadily for weeks. My examina- 
tion of the blood revealed no trace of malarial parasites. The red cells 
numbered 3,120,000; the leukocytes, 4800, the different varieties being 
present in approximately normal percentages. 

By the blood examination just reported leukemia could be excluded. 
I have seen a very similar clinical picture produced by myeloid leukemia, 
but the blood was in that case very distinctive and the chills less num- 
erous. 

As the patient has a history of gall-stone colic and has now an irregu- 
lar fever with chills and enlargement of liver and spleen, it is natural to 
consider for a moment the possibility that he may now be suffering from 
gall-stone fever. The condition of the abdomen and the course of the 
temperature are consistent with that diagnosis, although the spleen is 
unusually large; but gall-stone fever is almost always accompanied either 
by attacks of pain or by more or less transient yellowing of the conjunctiva 
during some part of the attack. 

The irregular surface of the liver, if it be taken as an established 
fact, is of great diagnostic importance, as there are but two common 
diseases which produce hepatic enlargement with irregularities of surface 
palpable through the abdominal wall, viz., cancer of the liver and syphilis 
of the liver. Both of these diseases may be associated with fever, though 
this is more common in syphilis. The age of the patient, the freedom 
from marked gastric symptoms, and the size of the spleen point distinctly 
toward syphilis rather than cancer. 

As soon as I asked the patient the direct question, he admitted that he 
had had syphilis seven years previously, and been treated for it by a well- 
known specialist whose diagnosis I knew to be irreproachable. The 
patient had concealed this portion of his history even from his attending 
physician, who had not happened to ask him the direct question. 

Outcome. — The patient was at once put on intramuscular injections 
of mercury with 15 grains of potassium iodid after each meal. By June 
28th his fever was abating and general improvement quite noticeable. 

He afterward made a complete recovery. 

Diagnosis. — Syphilis, 




Fig. 79. — Physical signs in Case 215. No dulness; no bacilli in sputa; died of phthisis 

in two weeks. 




Fig. 80. — Physical signs in a case of unexplained fever. Practically no cough. 



FEVERS 4Q9 



Case 215 



I was called October 24, 1905, to see a young man of twenty-four — a 
steam-gage fitter. I reproduce the history as it was given to me. 

He had complained of a week's increasing dyspnea and great lassi- 
tude. The attending physician, who saw him at the beginning of this 
illness, had kept a temperature chart which showed that there had 
been fever each day, rising to 101 or 102 ° F. at night. The pulse 
range was from 100 to 112. The respiration rate showed a steady 
rise — 28 for four days, 30 for the succeeding two days, and 36 for the 
past twenty-four hours. There was much sweating with the fever, 
but no pain and no other symptom except a slight, dry, hacking cough, 
which was not complained of and produced nothing until the day 
previous, when a single small mucopurulent mass was expectorated. 
This was examined at the Board of Health laboratory and found to be 
negative. The urine — 1025 — contained a trace of albumin, a few 
fine and coarse granular casts, and a positive diazo-reaction. 

The blood showed no YVidal reaction. There was no wound or other 
known source for sepsis; no history of syphilis; no recent gonorrhea. 
The chest and abdomen had been examined with negative results. 

What possibilities should be here investigated? 

1. The past history should be scrutinized. 

2. The physical examination should be repeated with special reference 
to the presence of — 

(a) Central pneumonia; (b) endocarditis and pericarditis; (c) 
typhoid; (d) miliary or generalized tuberculosis. 

Further investigation of his past history showed that he had always 
been well, although in the previous August he had had some swollen 
glands in the side of his neck, which persisted for three weeks and 
were accompanied by night-sweats. After that he felt very well and 
went to work again. 

Physical examination showed the signs indicated in Figs. 79 
and 80. The heart and pericardium showed nothing abnormal. 
The temperature chart [showing a normal or subnormal temperature each 
morning] was practically sufficient, considering the previous course oi 
the illness, to exclude typhoid and central pneumonia. The Leukocyte 
count, which was normal, added to the evidence againsl pneumonia. 

The boy did not cough at all during my visit, but the character oi 

Lgns, when taken in connection with the fever and other symptoms, 

to me to point strongly toward pulmonary tuberculosis, of which 

;c died two weeks later. 



4io 



DIFFERENTIAL DIAGNOSIS 



The attending physician was much surprised and rather skeptical 
at my diagnosis, "for," as he said, "the boy has practically no cough, 
almost no sputa, and what he does raise has been examined and found 
negative." It cannot be too strongly insisted, in view of this and many 
other similar cases, that a negative sputum examination, unless it has 
been many times repeated, should never be considered as evidence 
against pulmonary tuberculosis. Even then it is by no means conclusive, 
as bacilli may not appear for many weeks or even months after the onset 
of the disease in the lung. 

Diagnosis . — Pulmonary tuberculosis. 

Case 216 

On January 18, 1897, soon after the discovery of Widal's reaction 
in typhoid fever, I was asked to examine the blood of a febrile case in 
which that diagnosis seemed fairly certain. Some confirmation, how- 



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ever, was desired. Four weeks previously the patient had had a mastoid 
operation following an attack of otitis media. All had gone well, and 
the wound was now almost healed; only a small area of healthy granu- 
lations remaining in the mastoid region. Nevertheless, soon after the 
operation the patient had begun to have fever, the course of which is 
shown in the accompanying chart (Fig. 80). 



FEVERS 



411 



Throughout its course he had complained of nothing except such 
discomforts as could be reasonably attributed to the fever itself. He 
had had no headaches, no tenderness at or near his wound, no symptom 
that would serve to localize any cause for the fever. 

At the time of my examination a group of typical rose spots were 
scattered over the abdomen. Each spot was about 2 mm. in diameter, 
and disappeared wholly on pressure. The spleen was not palpable, 
and visceral examination was otherwise negative, with the exception of a 
few scattered rales at the base of each lung. 

The blood examination showed leukocytes, 23,000, 88 per cent, of 
which were polyrmclear. The Widal reaction was entirely negative, 
even in dilutions of 1: 10. 

Discussion. — I reported to the surgeon in charge of the case that it 
was not one of typhoid fever, and that I believed some type of wound 
infection must be present. At that time I did not know of the common- 
ness of infectious thrombosis of the lateral sinus and jugular vein, since 
so thoroughly studied by Libman * in its relations to bacteriemia. 
Doubtless micro-organisms might have been cultivated from the cir- 
culating blood had I known at that time the importance of the test: 

A great skepticism of my results was expressed at the time. The 
chart was so typically that of typhoid, the rose-spots so diagrammatic, 
the patient so completely free from any local symptoms or complaints, 
that it seemed absurd to exclude typhoid on the evidence of so academic 
a laboratory test as blood examination. This was before we had been 
shown by thousands and tens of thousands of blood-counts that un- 
complicated typhoid never produces such a leukocytosis as that here 
recorded, and that the absence of a Widal reaction after four weeks of 
fever is strong evidence against the existence of typhoid. 

Outcome. — The patient died January 21st; autopsy showed a septic 
thrombosis of the lateral sinus and jugular vein. 

Diagnosis. — Septic thrombosis of the lateral sinus and jugular vein. 

Case 217 

A physician of thirty-nine was seen November 30, 1905. Six years 

previously he had had the grip, followed by weakness, emaciation and 

night-sweats. Pulmonary tuberculosis was suspected, but not proved. 

ent south for two months and recovered entirely, and has since then 

ery hard, "mostly," he says, M ou his nerve." 

August [7, 1905, a hair follicle on his linger got infected. It WES 

l The [mportance of Blood Culture In th<- Study of Inf ectiont of Otiti Origin, by 
man and II. L. Celler, Trai tmer. Physicians, [9 0, p. 



412 DIFFERENTIAL DIAGNOSIS 

opened and cureted on the nineteenth under cocain. He felt much ex- 
hilarated thereafter, and made his medical calls as usual throughout the 
rest of the day. In the evening he collapsed, and had a very severe pain 
in the right intercostal region, accompanied by high fever not relieved by 
poulticing, and only modified by f grain morphin. Next day the signs 
of pleurisy were found, and two days later an area the size of an orange 
appeared near the angle of the right scapula. Over this the breathing 
was bronchovesicular, with dulness and crackling rales. These signs 
lasted without much change for four weeks, and were not wholly gone for 
two weeks more. An irregular fever persisted throughout. 

October 6th, though still weak, and despite the presence of high- 
pitched respiration over the area described above, he felt well enough 
to be moved to the White Mountains, where he rapidly improved, ate 
well and slept well, took four-mile walks, and had no cough to speak of. 
He had several bad headaches, but otherwise felt well and returned to 
work October 26th. At this time his lungs were examined and found 
normal; his sputa contained no bacilli and no elastic fibers. The day 
after his return he got overtired and again collapsed, i. e., could not talk, 
eat, or sit up, had a bad headache, and was awake all night. 

Next day he felt better, and the day after felt "like a fighting cock.'' 
During the next ten days he did his medical work as usual, although he 
felt somewhat poorly every second day. November 3d he did a very 
hard day's work, and at the end of it felt chilly and languid. His tem- 
perature was found to be 102 ° F. From November 3d to November 
30th — the day on which I saw him — he had an irregular fever, accom- 
panied by headaches. All his symptoms tended to be worse every second 
day. 

Two of his colleagues saw him in consultation November 10th, 
the diagnoses considered being grip, malaria, and simple nervousness. 
The spleen was felt, and accordingly quinin, 24 grains daily, and Fowler's 
solution, 5 minims three times a day, were administered. The quinin 
hammered the temperature down, but it rose again as soon as the drug 
was stopped. The blood was twice examined at this time, and found 
to be normal; no anemia, no leukocytosis, no Widal reaction. The urine 
was also normal (November 13th). 

By this time the doctor — always of a very high-strung nervous tem- 
perament — had gotten so worked up about himself that he was again sent 
to the country, but while there still had fever, ranging from 100 ° F. in 
the morning to 101.4 F. in the evening, despite the administration of 
quinin, 24 grains a day. During the last two weeks he has had ten days 
of pain over the lower left back, in the region of the diaphragmatic 




Fig. 82. — Physical signs simulating pulmonary tuberculosis in a case ot sepsis with pros- 
tatic and perinephric abscess. Complete and lasting recovery followed. 



FEVERS 



413 



attachment. Throughout the last ten days of his fever he has also had 
pain in urination, and for the past few days some distress in the rectum 
and perineum. 

On the twenty-ninth of November he returned to his home feeling 
pretty poorly and eating very little. 

Examination November 30th showed temperature ioo° F., no emacia- 
tion, abdomen negative, spleen not felt, lungs as per diagram (Fig. 82). 

Discussion. — Typhoid and malaria, it seemed to me, could be easily 
ruled out. I could find no evidence of any form or focus of sepsis. 
Accordingly, I made the diagnosis of pulmonary tuberculosis. December 
1 st the prostatic symptoms became more marked; tenderness and fluc- 
tuation appeared in the perineum and a large prostatic abscess was 
evacuated. 

December 10th, tenderness and swelling appeared in the region of the 
left twelfth rib. Incision liberated a large amount of pus from the region 
of the kidney, which was not felt or seen. The patient made an unevent- 
ful recovery, and has been well ever since (October, 1910). 

I made two chief mistakes in this case: first, in forcing myself to 
make some diagnosis, even an improbable one, because everything else 
seemed more improbable. The proper course would have been to wait 
until something more distinctive appeared. 

My second blunder was in paying so little attention to symptoms on 
the part of the bladder and rectum, which, though very trifling at the time 
when I saw the patient, were enough to suggest the presence of a septic 
focus which became evident within twenty-four hours. 

Diagnosis. — Perirectal abscess; perinephric abscess. 

Case 218 

A married woman of thirty-two consulted me in October, 1908, ac- 
companied by her physician, who was an intimate friend of the family. 
The diagnosis was splenic anemia, and the problem presented to me for 
consideration was whether splenectomy should be done. 

The patient's complaints were of general weakness, languor, and a 
dragging sensation in the left axillary region. A slight continued fever 
was found to be present. The spleen reached almost to the navel, and 
appeared to be unusually immobile, perhaps owing to the presence of 
adhesions. Visceral examination was otherwise- negative. The blood 
showed 3,500,000 red cells, 8000 leukocytes, 45 per cent, of hemoglobin. 
The differential count showed nothing worth}- of note. The red cells 
showed in the stained smear a marked achromia with slight variations 
in size. Xo nucleated red cells were seen. 



414 



DIFFERENTIAL DIAGNOSIS 



The patient was advised to enter the hospital for more careful study, 
and probably for an eventual splenectomy. She delayed, however, 
nearly three months before accepting this suggestion. Meantime there 
had been a considerable accumulation of fluid in the abdominal cavity, 
and tapping had already been required about two weeks before her 
entrance to the hospital. 

A reexamination of the patient at this time showed, except for the 
ascites, no especial change as compared with the conditions previously 
found, although the anemia had slightly increased. The temperature 
continued slightly elevated, the pulse, respiration, and urine normal. 
Blood-pressure, 125. Although I was somewhat apprehensive that he- 
patic changes might have progressed so far as to prevent the splenec- 
tomy from relieving her symptoms, it seemed as if she were going on from 
bad to worse in spite of all that good hygiene and the administration of 
iron and arsenic could do; hence it seemed best to go on with the splen- 
ectomy, perhaps preceding it by a direct transfusion of blood. 

At this juncture Dr. Wilder Tileston saw the patient at my request, 
and, in conversation with him, the patient mentioned that she had been 
troubled for a long time with catarrh and cold in her head. "It had 
been there so long," she said, "that I am getting quite used to it; but 
a little while ago, as I was blowing my nose, something came away, and 
I noticed that there was a passage from one nostril to the other, inside." 

Discussion. — Following up this hint, Dr. Tileston learned that she 
had had "some sort of skin disease" in her scalp, as a result of which 
there were still marked unevennesses over the cranial vault, though the 
skin was wholly normal. 

No other evidences of her previous syphilis were demonstrable either 
in the history or in the physical examination, but the facts seemed to 
me to warrant an immediate abandonment of the plan for splenectomy 
and a thorough trial of antisyphilitic treatment, which she had never 
had. As a result of this she gradually returned to perfect health, the 
spleen diminished to one- quarter its former size, the anemia and ascites 
disappeared, and the patient was enabled to take up her usual mode of 
life. 

This was a very narrow escape from a serious mistake. There was 
nothing in the history, as given to me, to suggest syphilis. Doubtless 
I was misled partly by the obvious innocence of the woman, partly by 
the fact that her physician, who was intimate both with her and with 
her husband, had clearly no idea that the husband had been infected 
previous to marriage. Nevertheless, I ought to have considered syphilis 
merely from the association of the enlarged spleen and ascites with an 




Fig. 83. — Chest signs obtained on physical examination of Case 219. 




Fig. 84. — Pencil sketch from an #-ray plate of Case 219. 



FEVERS 



415 



anemia of unknown cause, for in that text-book which we should all 
know by heart I find the following, under Syphilis of the Liver: 

" In a second group of cases the patient is anemic, the liver is enlarged, 
perhaps irregular, and the spleen also is enlarged. Dropsical symptoms 
may supervene." (Osier's Practice of Medicine, seventh edition, p. 
276.) 

Diagnosis. — Syphilis. 

Case 219 

A boarding-school boy of sixteen was seen December 12, 1907. 
He had had a "regular cold" with a little fever which seemed to be 
ended three days ago, but next day the temperature rose again to 
102 ° F. Yesterday morning crackles were heard for the first time at the 
right base. Last night at midnight he vomiied and complained of pain 
in the right axilla on coughing. When examined at 7 P. M. his tempera- 
ture was 102 ° F., his pulse 90 and dicrotic. Except for slight disten- 
tion of the belly, the abdomen and extremities showed nothing abnormal, 
likewise the left lung. Examination of the base of the right lung behind 
showed in some positions nothing but enfeebled vesicular respiration, 
but when lyin^on the right side there were crackles, increased whisper, 
and a small patch of feeble bronchial breathing near the angle of the 
scapula. 

Although these signs were not very distinctive, their association 
with a typical rusty sputum and a high leukocyte count seemed to me 
to justify a diagnosis of lobar pneumonia. On the nineteenth, as the 
temperature suggested an empyema, a needle was put in near the angle 
of the scapula, but only an ounce of bloody serum was obtained. On 
the twenty-fourth he was tapped again, this time in the axillary line, 
and an x-ray was taken of the chest, which showed nothing abnormal. 

January 3d the temperature was normal, the boy hungry and sleep- 
ing well, but the chest signs were still far from normal. On January 
6th the temperature rose again, and though the boy was still eating, 
sleeping, and feeling finely, the signs were as in the accompanying 
diagram (Fig. 83). The front of the chest and the axilla showed 
nothing of importance. The boy's temperature was 101.6 F. in the 
morning, og.4 F. in the afternoon. January 7th it was 102.2° F. in 
the morning, ioo° F. in the afternoon. Between this date and the 
COnd of January two other unsuccessful taps were made. 
The boy continued in excellent condition despite his daily fever. The 
sputum was repeatedly examined, with negative results. 

At this time he was moved to New York city and put in charge of 



416 



DIFFERENTIAL DIAGNOSIS 



Dr. Evan Evans. A second #-ray made at this time showed the appear- 
ances sketched in Fig. 84. January 2 2d pus was finally found under 
the scapula by a puncture made through the axilla. The boy made an 
excellent recovery. 

Diagnosis. — Interlobar postpneumonic empyema. 

Case 220 

A girl of six entered the hospital November 18, 1907. She has 
always been weak, and often complained of her ears. She has had 
measles, chicken-pox, and whooping-cough. Three days before en- 
trance she fell and hurt her head. That night she was feverish and 
complained of headache. The next day, her mother said, she "never 
opened her eyes." She has vomited watery material several times, 
and continued to complain of pain in her head, also in the abdomen. 
She has been somewhat constipated. She has been in bed two days. 

Physical examination showed a red throat, but two cultures, taken 
November 18th and November 2 2d, were negative for diphtheria. The 
ears were also negative; no stiffness of the neck; no glandular enlarge- 
ment. The mucous membrane of the mouth was normal. The chest 
and abdomen normal. The edge of the spleen was felt. The urine 
was free from albumin and sugar. There was no edema. The blood 
was normal. The chart was as follows: 



^fe^ 




Fig. 85. — Chart of case 220. 



FEVERS 417 

Discussion. — The fevers of children give rise to far more diagnostic 
difficulties than those of adults. Children's temperatures undergo 
far wider and more numerous oscillations in perfect health than adults' 
temperatures. Besides these supposedly normal variations, there are 
a great many short periods of pyrexia occurring in children who are more 
or less out of sorts without any reason at present assignable. 

In addition to the variations just alluded to, children are subject to 
many fevers lasting several days "with nothing to show for them" — 
i. e., without any obvious local physical signs and without any com- 
plaint to direct our search to any organ or tissue. Among the commoner 
causes ultimately discovered for such fevers are: 

(a) The onset of the exanthemata. 

(b) Infections of the heart and pericardium, with or without joint 
pains (" rheumatic "). 

(c) Otitis media (without any discharge or complaint on the child's 
part). 

(d) Urinary infections ("pyelitis," ascending or hematogenous). 

(e) Empyema (without pain, cough, or dyspnea). 
(/) Poliomyelitis. 

(g) Tuberculous meningitis. 

(h) Typhoid fever. 

In all such cases the best that we can do is to make repeated and 
comprehensive examinations of the child, who is meantime kept in bed, 
given an easily digested diet and plenty of water to drink. Sooner or 
later, if we are vigilant, something comes to light. The points neglected 
in the present case will be obvious from the outcome. 

Outcome. — On the twenty-fourth repeated examinations from head 
to foot still showed no cause for her illness. She slept and ate fairly 
well, and took an interest in what went on. 

November 29th: "Several nights ago she complained of pain in the 
left leg. Next morning the left knee-jerk was absent, the right easily 
obtained. It was found that the child's mother had been bringing her 
chocolate candy and that the child had eaten about a quarter of a pound 
of it, hiding the box at night under her bed clothes." 

That night her urine was reported to be full of non motile bacilli 

mbling colon bacilli. 

December 8th: "The knee jerk on the left is sometimes present, 

sometimes absent, sometimes obtained after long trials. ( )n walking the 

child drags the left foot ever so little. There is DO muscular atrophy. 

A considerable amount of pus appeared in the urine on the fifth of Dccem- 

27 



4i8 



DIFFERENTIAL DIAGNOSIS 



ber, and this has increased since. Urotropin, 5 grains thrice daily, and 
abundant water were given." 

On the twenty-fourth of December a little drooping of the left shoul- 
der was perceptible, and the left foot still dragged a little. 

January 2d, the urine being free from abnormalities, the child was 
discharged well. 

Diagnosis. — Poliomyelitis; renal infection. 

Case 221 

An Irish laborer of eighteen entered the hospital May 20, 1908. On 
the recommendation slip from the out-patient is written: "Appendicitis? 
Typhoid? Tuberculosis? " His father and one brother died of phthisis. 
The past history is good. On the fourth of December he began to have 



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pain in the stomach, which has kept him awake at night off and on ever 
since. There is no vomiting; no appetite. He has also been coughing 
for the same period, with a good deal of sputa. 

Physical examination shows slight emaciation, enlarged tonsils, es- 
pecially the right, but no exudate. The heart is normal. The lungs 
show a few scattered crackles and squeaks. The right half of the ab- 
domen is slightly more resistant than the left, and in the region of the 
cecum there are marked local tenderness and a mass about the size of an 
egg. The edge of the spleen is just felt on full inspiration, likewise the 



FEVERS 



419 



edge of the liver. The knee-jerks are obtained with difficulty. There 
are old, irregular scars on the backs of both hands and at the lower end of 
the right ulna. Leukocytes, 2800. 

At no time was there any considerable abdominal spasm. By May 
2 2d the tenderness in the abdomen was "one. 

Discussion. — Remembering the great susceptibility of the Irish 
to tuberculosis, the patient's family history, and the long persistent cough 
of which he complains, we cannot but consider the possibility of a 
tuberculosis, pulmonary or generalized. The signs in the lungs are con- 
sistent with miliary tuberculosis, but not in any way characteristic of 
that or of any other pulmonary affection. The sputa should, of course, 
be repeatedly examined. (This was done, but with negative results.) 
A tuberculin reaction might be tried, but would be significant only in 
case it was negative, as the vast majority of adults react positively, 
owing to the latent obsolete foci of tuberculosis. Had the disease been 
of the ordinary pulmonary form, the signs in the lungs should have been 
more extensive, in view of the long duration of the cough. 

Tuberculous peritonitis with glandular masses and adherent coils of 
intestine near the cecum might explain many of the symptoms, though 
one would expect more abdominal spasm and tenderness. 

Appendicitis must, of course, be considered, though the local signs are 
few and slight, and the cough and splenic enlargement could not be thus 
explained. The leukocyte count is also surprisingly low for appendi- 
citis. 

The scars upon the back of the hands and on the right forearm re- 
semble those sometimes produced by syphilis. The splenic and hepatic 
enlargement, the cough, and fever might thus be explained, and the 
absence of any history of this infection is of no importance. Without 
further evidence, however, one would not resort to the therapeutic test, 
at any rate until other probabilities had been excluded. 

The diagnosis of typhoid fever would explain the present symptoms 

verv well. Many cases of typhoid exhibit a certain amount of tenderness 

in the appendix region, and this patient's lung signs are those- usually 

found in typhoid. We are puzzled, however, to explain the long duration 

of symptoms. This man can hardly haw had typhoid from December 

4th to May 20th, and if we suppose the typhoid to have begun more 

tly, we have no means of conjecturing what other disease he may 

had previously. Evidently, what we most nerd at the present 

• ire is a W'idal reaction and Mood culture. 

Outcome. The W'idal reaction wasfound to be positive May 20th, 

and typhoid bacilli were isolated at the same time from the ear Mood. 



420 



DIFFERENTIAL DIAGNOSIS 



The course of the disease thereafter was uneventful. The patient went 
home perfectly well on the fourteenth of July. 
Diagnosis. — Typhoid with relapse. . 

Case 222 

A salesman of nineteen entered the hospital June 22, 1908, with a 

negative family history and good habits. Four months ago, in Georgia, 

he had a fever which kept him in bed for six weeks and a half. The 

blood was not examined. He had been given capsules with considerable 

relief. Six days ago he had a chill, followed by headache, fever, and 

nosebleed. Four months ago he weighed 

154 pounds, now he weighs 124 pounds. 

Physical examination showed a soft 

systolic murmur, heard all over the pre- 

cordia, while the first sound at the apex 

was very faint. The pulmonic second 

was greater than the aortic second sound. 

There was no enlargement or irregularity. 

The arteries were palpable between beats. 

Liver dulness extended from the sixth rib 

to a point two inches below the costal 

margin in the parasternal line. The soft 

edge of the spleen was felt on inspiration. 

The course of the temperature is shown 

in the accompanying chart. The white 

cells were 4300. Widal reaction negative. 

No malarial parasites were found in the 
Fig. 87.— Chart of case 222. blood. 

Discussion. — Estivo-autumnal malaria is naturally our first guess 
in the case of a febrile patient who has recently returned from Georgia, 
but this is at once ruled out by the negative examination of the blood ' 
and the good condition of the patient. If he had had estivo-autumnal 
malaria in his system for four months, his spleen would have been 
harder and probably larger, his general condition worse. 

Endocardial fever is suggested by the presence of a cardiac murmur 
and long duration of symptoms, but the leukocytes are rarely so few in 
this disease, and the murmur may well be explained as "functional." 

What inference should be drawn from the extension of liver dulness 

1 Very rarely malarial parasites are not to be found in the peripheral circulation at a 
single examination during the febrile stage of estivo-autumnal malaria. I have known of 
but one such case. 



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FEVERS 



421 



two inches below the costal margin? Should we consider some of the 
hepatic diseases which aie often associated with fever (hepatic syphilis, 
abscess, cholangitis, leukemia)? I think not, for we have no good 
reason to believe that the liver is enlarged. The extension of dulness 
below the costal margin should never, in my opinion, be taken as evi- 
dence of hepatic enlargement unless the edge of the organ is also palpa- 
ble. Dulness below the right ribs, continuous with that of the liver, 
is to be found in countless cases which never show any other evidence 
of hepatic enlargement. 

The loss of thirty pounds in four months makes us suspect tuber- 
culosis hidden somewhere in the body, but there seems to be no good 
evidence to support this suspicion, though tuberculosis cannot be 
positively excluded. 

We must ask ourselves the question, Can this be the "fag-end" of 
a typhoid despite the absence of a Widal reaction? The time of year 
is not at all the usual one for such an infection, and at first sight we 
should suppose that after so long an illness the patient would either 
be well or dead if he had had typhoid all that time. Experience shows, 
however, that just such a history of long, indefinite illness is to be ob- 
tained in many cases which turn out eventually to be unmistakable 
typhoid. Xo one, so far as I know, has adequately accounted for this 
fact, but no one who has seen much typhoid will dispute it. It is com- 
monly explained by saying that the patient has probably had most of 
his typhoid before he came under observation, and that what we are 
seeing represents the end of a relapse — perhaps the second or third 
relapse that he has had. This is perhaps the most plausible expla na- 
tion, although we should expect the patient to be much more exhausted 
as we recall the appearance of patients who have had two or three 
relapses under treatment. We must reject the blasphemous thought that 
the patient may be in good condition because he has had no treatment. 

The present case, however, is hard to explain, even by this rather 
far-fetched hypothesis, for he had his six weeks and a half of fever four 
months ago, and has, since that time, been up and about his 1hisuh's> 
until he was suddenly seized with a chill on June [6th. It remains 
to me a mystery, although a very familiar one, many examples of which 
each autumn when patients in the typhoid ward relate very cir- 
cumstantially the rour>e of an illness which has lasted all summer. 

Outcome.- On the twenty-fourth of June the Widal reaction was 
positive. The patient was out of bed July 10th and discharged well 
on July i8th. 

Diagnosis. Typhoid (brii 



422 



DIFFERENTIAL DIAGNOSIS 



Case 223 

An Italian laborer of twenty-eight entered the hospital September 
23, 1906. His family history, past history, and habits are good. Three 
weeks ago he went to bed with a headache and has been there ever 
since. His appetite is good, but he has not been allowed to eat much. 
His bowels have been constipated. There has been no cough. He has 
had three nosebleeds. 

On physical examination the pupils were found to be slightly irregular, 
the right larger than the left. Both reacted normally. The glands in 
the neck, axillae and groins were palpable, but not enlarged. Physical 



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examination was otherwise negative, also the urine. The eye-grounds 
were normal. White cells, 7000. 

Discussion. — One's first impression would be that there is really 
not much the matter with this man. His temperature is practically 
normal, his organs negative to physical examination. But on second 
thought we must recognize that a young Italian laborer does not stay 
in bed three weeks for the fun of it. Something must be the matter with 
him, and his doctor says that he has had a fever. 

A very considerable proportion of Italian laborers appear to have 
had syphilis. The irregularity of the pupils and the palpable glands 
seemed to support this idea; but it was not possible to get beyond the 



FEVERS 



423 



region of conjecture as regards syphilis, for the YVassermann reaction 
was not then in use. 

The slow pulse and the rather persistent headache might be taken 
as evidence pointing toward brain tumor or other cerebral lesions; but 
this suggestion, like the others, had to be left hanging, as there were no 
sufficient grounds for a more positive decision. 

At this time of year and in a patient with this history it is always 
advisable to try a YVidal reaction. The result of it was, in this case, 
extremely interesting, as is indicated by the outcome. 

Outcome. — The YVidal reaction was strongly positive at entrance. 
The later course of the temperature is shown in Fig. 88. The patient 
went home, apparently well, on the twenty-second of October. 

Diagnosis. — Typhoid (afebrile when first seen). 

Case 224 

A housewife of thirty-seven was seen March 16, 1907. Her family 
history was good. She has never been sick before. She has been nursing 
her twelve-year-old girl, who has been sick for three weeks with fever, 




i'ig. 89. — Chart of i ai 



diarrhea, thirst, and stupor. Yesterday her boy of fourteen was also 

Sick. She has felt tired from nursing her children, but did not call 

k until the doctor took her temperature at p. M. t<> day, and 



424 



DIFFERENTIAL DIAGNOSIS 



found it io2° F. She sleeps well, but is constipated and has a rather 
poor appetite. 

Examination showed an obese, apathetic woman, her scalp covered 
with crusts. A soft, blowing systolic murmur was heard over the pre- 
cordia, loudest in the pulmonary area. The pulmonic second sound was 
accentuated, the heart not enlarged. The lungs and abdomen were 
negative. White cells, 4600; Widal reaction negative. The bowels 
moved daily. On the twenty-sixth she began to surfer from diarrhea 
with distressing tenesmus, which lasted three days, and on the same day 
she passed a small amount of blood, the pulse not being at all affected. 

On the twenty-eighth, rectal examination revealed a large mass of 
feces just inside the anus. Removal of this relieved all the symptoms. 

On the third of April she complained of a burning micturition. The 
urine showed nothing abnormal except extreme acidity. Citrate of 
potassium and cream of tartar water promptly relieved this symptom. 
She was discharged well on the twenty-seventh. 

Discussion. — When a woman has a fever and nothing to show for it; 
when the leukocytes are subnormal and two others in the same family 
have febrile illnesses, the chances are strongly in favor of the assump- 
tion that she has typhoid fever, probably acquired by contact. In the 
present case the Widal reaction appeared March 20th, but the diagnosis 
was easily made before that. 

The case is introduced here to exemplify the occurrence of diarrhea 
and tenderness due to fecal impaction in typhoid fever, even though the 
bowels had been moving daily. Such cases are not at all uncommon, and 
if rectal examination is neglected, the trouble is rarely recognized, and 
may cause much suffering. It usually occurs toward the end of the case, 
at or near the period of defervescence, coming on quite suddenly and 
without warning. The accumulation is often so great that it has to be 
removed mechanically. The lesson forced upon me by my failure in one 
such case was never to neglect rectal examination in a case of diarrhea. 

Of some interest also is the dysuria, which the therapeutic tests ap- 
parently prove to be due to hyperacidity of the urme. 

Diagnosis. — Typhoid; impaction; dysuria. 

Case 225 

A rubber worker of thirty-seven, a Swede by birth, entered the 
hospital June 10, 1908. His family history and past history were good, 
except that he had "typhoid" at the age of eighteen, and "malaria"" 
for a week a year ago. 

Two weeks ago, while at work, he had a severe chill and abdominal 



FEVERS 



425 



cramps, which doubled him up. After three hours he went to work 
again and kept on for the next two days, when he had to give upon account 
of weakness and pain in his stomach. He has been in bed for a week. 
To-day he vomited twice; he has had no appetite, poor sleep, moderate 
constipation. He has passed urine only twice in each twenty-four hours 
during the last two weeks. What hi- passes is very red. 

Physical examination showed obvious loss of weight. Cardiac dul- 
ness extended one inch beyond the right border of the sternum. No 
cardiac impulse was seen or felt. There was nothing abnormal about 
the sounds. The left lung showed bronchial respiration above the 
clavicle, bronchovesicular respiration and increased voice-sounds down 




Fig. 90. — Chart of case 225. 



to the second rib. Below that level voice-sounds, breath-sounds, and 
tactile fremitus were diminished; percussion was dull to flat The abdo- 
men was quite negative. The white cells were 7400; the urine negative. 

The chest was tapped on the eleventh and 40 ounces of dear, pale 
yellow fluid removed. Specific gravity, 1017; albumin, 2.8 per cent.; 
lymphocytes, 97 per cent. 

On the sixteenth 64 ounces more were removed from the chest I >n 
the twentieth it was tapped a third time, but only to ounces found. 
On the twenty eighth it was again tapped and 70 ounces wen- removed. 

t a month before entering the hospital was 155 pound-. At 

the time of his discharge [24 pounds. 



426 DIFFERENTIAL DIAGNOSIS 

Discussion. — In rubber workers we meet with all sorts of .obstinate 
and debilitating symptoms which oftentimes refuse to be grouped into 
any recognizable disease, although lead colic sometimes emerges from 
the obscurity, in case the workers deal with that part of the process of 
manufacture in which lead is used. But, so far as I am aware, none of 
the toxic effects of work in a rubber factory produces fever. 

The patient's account of himself gives us no inkling of what may be 
the cause of the fever. Physical examination and the results of aspira- 
tion leave no doubt that the patient has been suffering from a pleural 
effusion. It is unusual, however, to observe so rapid a reaccumulation 
of the fluid. In the vast majority of cases of ordinary tuberculous pleur- 
isy a single tapping suffices, or if recurrence takes place, it is far less 
rapid than in the present case, which suggests another and more ominous 
possibility. 

Whenever rapid and frequent reaccumulation of pleural fluid occurs 
in a case believed to be one of ordinary (tuberculous) pleurisy, we should 
always suspect malignant disease of the lung, pleura, or mediastinal 
glands, no matter how young the patient and despite the absence of all 
pain. I have twice made the mistake of diagnosing as pleurisy a case 
which turned out to be malignant disease with secondary effusion. Malig- 
nant disease not infrequently produces a bloody effusion, but this is by 
no means invariable. 

The #-ray gives us usually but little assistance in doubtful cases of 
this type, as the collapsed lung may simulate the shadow produced by 
malignant disease. The cellular elements of the sediment may be iden- 
tical in both diseases. The first clue obtained in most doubtful cases is 
the appearance of a metastasis in one of the external lymph-glands or 
elsewhere. Later the steady decline in the patient's strength makes 
it obvious that something more serious than pleurisy underlies the 
effusion. 

Outcome. — After July 28th there was no further reaccumulation 
and the patient rapidly improved. On August 6th he went to Rutland 
Sanatorium. 

Diagnosis. — Pleurisy (tuberculous) . 

Case 226 

A young married woman of twenty was first seen January 27, 1904. 
Two months ago her second child was born. Hemorrhage and cureting 
followed. 

Fever and chills for three weeks. (See Fig. 91.) No pain what- 
ever. No other complaints. 



FEVERS 



42 7 



Physical examination negative. Widal, negative. Whites, 7000. 
The case was considered by Dr. R. H. Fitz a mild septicemia. The 
uterus was dextroretroverted. Cervix very soft. Uterine body very 
hard. Culs-de-sac free. The uterus was dilated and curetcd. 

February 19th vaginal examination showed some edema in right iliac 
region. 

Discussion. — This woman complained of nothing in the world but 
fever. As she had rather recentlv emigrated from Italv, had had re- 
peated chills and irregular fever, her blood was many times examined 
for malarial parasites, but none were found. 

After this, typhoid was considered, although the chart was very 
unlike it, and the patient showed at no time any hebetude. The Widal 




Fig. 91. — Chart of case 226. 



reaction was done a number of times, always with negative results. 
Nevertheless, typhoid could not positively be excluded. 

Since the symptoms came on soon after her confinement, there 
seemed good reason to believe that the case might be one of mild sep- 
ticemia, pelvic in origin. The dilating and curetage were done with 
this idea in mind, but no improvement followed, and the diagnosis 
remained altogether in doubt. 

Mesenteric and peritoneal tuberculosis arc especially common in 
recent immigrants of the Italian race, and it is impossible- to exclude 
this diagnosis, though there were no signs of fluid in the peritoneal 
cavity, no palpable glandular masses, and only a moderate genera] 
abdominal spasm, rather more marked in the lower half. 

Outcome. The patient was examined under ether on the twenty- 
third of February, and a mass was felt in the region of the cecum. The 

abdomen was then opened, and the mass found to consist of Cfl 



428 



DIFFERENTIAL DIAGNOSIS 



glands intimately adherent . to the cecum. Microscopic examination 
proved tuberculosis. After a long illness the patient finally made a 
perfect recovery. 

Diagnosis. — Pericecal tuberculosis. 

Case 227 

A carpenter of twenty-seven entered the hospital February 17, 1907, 
with an excellent family history and past history. He drinks one or 
two pints of beer a day, rarely a glass of whisky. His habits are other- 
wise good. 

Two weeks ago he "got a cold," and felt sick enough to go to bed, 
although free from pain. Since then he has had a slight cough and has 



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raised a little sputa, which he describes as black and white. He says 
he feels tired all over, and for the past three days has had some pain 
in the right axilla and in the region of the right nipple, not increased by 
deep breathing. To-day his only complaint is of weakness. His 
appetite is good, his bowels regular, but he thinks he has lost much 
weight. (For the temperature, see the accompanying chart.) 

On physical examination the heart showed nothing abnormal. 
The left lung was negative, save for a few scattered rales. Throughout 
the right lung fine crackles were heard, with slightly diminished voice- 



FEVERS 429 

sounds, except at the apex, where they were slightly increased, with 
a little dulness on percussion. The edge of the liver was felt one finger's 
breadth below the ribs. Physical examination, including two examina- 
tions of sputa, was otherwise negative. The Widal reaction was always 
negative. The leukocytes numbered 12,400 on February 17th; 13,000 
on February 18th; 16,500 on February 22d; 11,900 on February 26th. 

Discussion. — It seems natural to associate the fever and the rather 
indefinite pulmonary signs as cause and effect, but it is hard to see 
how these signs can be considered sufficient to represent a pneumonia, 
an acute pulmonary tuberculosis, or an empyema, which are about the 
only lung diseases one would think of in this connection. Tuberculosis 
seems perhaps the more probable of the three, but we have no positive 
evidence of this in the sputa or elsewhere. 

Let us attack the problem from a different point of view. As I have 
elsewhere shown, 1 there are but three obscure continued fevers in New 
England which last over two weeks — typhoid, tuberculosis, and pyo- 
genic infections (sepsis). The other fevers, such as those due to menin- 
gitis, to acute articular rheumatism, to leukemia, pernicious anemia, 
syphilis, or malignant disease, are rarely "obscure" — that is, they show, 
as a rule, some obvious local lesions as their cause. Returning then to 
our case with this clue, it seems that we may exclude typhoid because 
of the continued leukocytosis, the continued absence of the Widal 
reaction, the excellent appetite, the absence of splenic enlargement, and 
the time of year. 

Sepsis is not so easily excluded, but the great majority of cases show 
either — (a) sl definite localized focus or source of infection, or (b), in 
the absence of such focus, a much more serious clinical picture. This 
patient does not seem much sick, especially when we compare his con- 
dition with that of patients with generalized pyogenic infection without 
demonstrable source. 

Can pulmonary tuberculosis which shows its presence by signs as 
slight and as few as in the present case be yet responsible for such 
marked and continued pyrexia ? Experience' shows that it can. Nothing 
is more remarkable, as one studies a large series of cases of pulmonary 
tuberculosis, than the discrepancies between the amount of lung Involved 
and the amount of constitutional disturbances, such as fever, prost ra- 
tion, emaciation, indigestion. Some patients in whose lungs two or 
three lobes are obviously infiltrated fee] scarcely sick at all, and keep 
about their work for many months. Others, in whom we can seauely 
.it enough physical signs to assure the diagnosis, are utterly 
1 Sec Referau <• on p. 403. 



43° 



DIFFERENTIAL DIAGNOSIS 



prostrated, drenched with sweats, constantly febrile, unable to digest, 
and rapidly emaciate. Presumably these differences are due in part 
to the variations in individual resistance, in part to the nature of the 
secondary infection ingrafted upon the original tuberculosis. 

Outcome. — After many examinations tubercle bacilli were finally 
demonstrated February 25th in a small speck of mucus which accom- 
panied about 30 c.c. of fresh blood. No typical signs of solidification 
appeared until March 6th. March 13th he was discharged worse. 

Diagnosis. — Phthisis. 

Case 228 

A teacher of thirty-four, of good family history, entered the hospital 
December 17, 1906. He had been told about eight years ago that he 



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had a weak heart. He had gonorrhea five years ago, syphilis eight 
years ago. 

Five weeks ago he "took cold," had a slight cough and fever, occa- 
sionally a little pain in the right knee, later in various other parts of the 
body, never constant or definite. He kept at work until five days ago, 
when he took to bed on the advice of his physician. He now feels 
some aching all over his body; he has no appetite, much constipation. 

The palpable cardiac impulse extends as low as the sixth space 
in the nipple line. There is harsh, systolic murmur, best heard at the 



FEVERS 



431 



apex, but also audible all over the chest. The pulmonic second sound 
is slightly accentuated. Dr. H. F. Vickery, who had previously seen 
him, stated that this murmur has been here for at least fourteen years. 
Physical examination is otherwise negative except for a leukocytosis 
of 19,200, and a fever ranging between 101 and 103 ° F. (See Fi^ r . 

930 

On December 23d, slight dulness and slight increase of voice were 
made out at the left pulmonary apex. The patient says he has worked 
very hard for more than a year and is tired out. He now sleeps most 
of the time, but complains of no discomfort. 

There was no change in his condition for the next month. He 
remained cheerful, his sleepiness gradually wore off and his appetite 
returned, but he continued to have fever. 

Pneumo vaccines were given, beginning March 17th, but produced 
no improvement. After the 12th of March the temperature became 
subnormal, and remained so for most of the following month, though 
the leukocyte count was persistently high, varying between 10,000 and 
34,000. On the twenty-fourth of March the red cells were 3,012,000, 
the hemoglobin, 50 per cent. Of the white cells, 92 per cent, were poly- 
nuclear and the rest lymphocytes. 

Discussion. — Another case exhibiting at the time of entrance a fever 
and nothing else. The constant leukocytosis makes it possible to 
exclude typhoid, and the other features of the examination rule out 
practically everything else except tuberculosis and some form of pyo- 
genic infection. The patient slept so large a portion of his time during 
the first month of his stay in the hospital that meningitis was at limes 
suspected, but at no time were there any physical signs tending to 
confirm this suspicion. 

The pulmonary signs described under the date of December 23d are 
such as are found in a great number of sick people if the examination is 
conducted with the utmost care in a quiet room. At the right apex 
they would have no significance whatever. At the left they call for 
more consideration, but are not in themselves sufficient to make us 
seriously fear pneumonia or tuberculosis. 

Whenever a continued fever accompanies a cardiac murmur such 
as that hen- described, there is reason to fear thai a vegetative endo- 
carditis is at work. But in the present 1 have reason to believe 

that the murmur lias existed for at least fourteen years, so thai its 

'.ition with this fever may not be significant. ( to the oilier hand. 

ondary anemia and the constant leukocytosis give us 

a to believe that the old process, which was re upon the 



432 DIFFERENTIAL DIAGNOSIS 

mitral valve fourteen years ago, has again become active, like some 
hitherto quiescent volcano. 

Outcome. — Beginning with March 29th, he had a great deal of 
vomiting, the vomitus containing considerable blood on one occasion. 
At this time there was little or no pulse to be felt in the right arm, although 
in the left it was fairly strong. Vomiting ceased within a few days, 
but the patient was left exceedingly emaciated and weak. Two pur- 
plish areas developed April 14th on the dorsum of the left foot; they 
disappeared during the day. Another appeared on the heel in the 
same afternoon. The patient began to be delirious about this time 
and he died on the twenty-first of April. 

Autopsy showed polypous endocarditis of the mitral valve; multiple 
infarcts of the spleen and kidneys; hypertrophy and dilatation of the 
heart. 

Diagnosis. — Malignant endocarditis. 

Case 229 

A housewife of sixty-seven entered the hospital February 10, 1909. 
She has seemed to be perfectly well until this morning, although she 
has noticed that her feet swell from time to time, and has been aware 
that she passed unusually large quantities of urine. She has had no 
headache and no vomiting. 

This morning she awoke at four o'clock, saying that she did not 
feel well. Within a short time she had several convulsions and became 
comatose. 

Physical examination showed a red, parched tongue, the heart's 
apex one inch outside the nipple line, the action regular and slow; 
there were no murmurs and apparently no increase in pulse tension, but 
the blood-pressure was 175 mm. Coarse and medium rales were 
scattered throughout both lungs. 

During the examination the patient had a general clonic convulsion, 
with frothing at the mouth, biting of the tongue, dilatation of the pupils, 
incontinence of urine and feces. The urine contained sugar, and had 
a marked reaction for acetone and diacetic acid. Gravity, 1021; albu- 
min, a slight trace; sediment, negative. The blood showed 25,000 
white cells per c.mm. 

The course of the temperature is seen in the accompanying chart 
(Fig. 94). 

Cheyne- Stokes' breathing began soon after the patient entered the 
hospital, and the aortic second sound was noted to be very loud. There 



FEVERS 



433 



was no evidence of meningitis, and a blood culture was negative. Con- 
vulsions followed each other in rapid succession. 

Within an hour of the time of entrance the patient was bled, 14 
ounces of blood being taken from the arm, and 2 pints of normal 
salt solution containing 5 drams of sodium bicarbonate were put into 
the vein. Convulsions, however, continued until the eleventh, when, 
under copious sweating by means of hot-air baths, and subpectoral 
infusions of salt solution, she began to improve steadily. 

On the thirteenth she was conscious, though confused. Sugar, 
acetone, and diacetic acid were gone from the urine, in the sediment 
of which many hyaline, fine and coarse granular casts were found, 





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some with fat adherent. The left pupil was now larger than the right, 
though both reacted normally. 

On the fourteenth she was at times rational, at times in a muttering 
delirium. She could swallow and took milk well, but had no control 
over the sphincters, and was occasionally noisy and profane. The 
white count had dropped to 8000. 

On the eighteenth she had hallucinations both of sighl and hearing, 
but when spoken to answered rationally. 

On the twenty second she was up in a chair, free from anv parahsis 

or anesthesia, quite rational in the day time, although a little irrational 

M night. She had no.' regained control Of the rectal sphincter. 



434 DIFFERENTIAL DIAGNOSIS 

On the twenty-fifth the urine showed no casts; leukocytosis was 
still absent. The Widal reaction was entirely negative. 

On March 9th she was able to walk about very well, and was 
to have gone home. At three o'clock she sank into a chair with a very 
poor pulse, and had a short convulsion, lasting only fifteen seconds, 
but followed by hallucinations of sight and hearing. She then sud- 
denly came to, remarked that she was afraid she had made a fool of 
herself, asked what had struck her, and remained quiet and rational. 

On March 12th she was discharged. 

Discussion. — The features of this case may be summarized as con- 
tinued fever with epileptiform attacks and glycosuria. 

The last item may be dealt with first. A patient seen for the first time 
with coma or convulsion should always be catheterized and the urine 
examined for albumin and sugar, yet I have known a very large number 
of mistakes arising from an inference made because either albumin, 
sugar, or both were found to be present. It should always be remem- 
bered that convulsions or coma, whatever their cause, frequently give 
rise to glycosuria, to albuminuria, or to both conditions. One must 
have other evidence before concluding that diabetes or nephritis is 
present. Such evidence is to be sought in the condition of the heart, 
in the previous history, and in the result of subsequent examinations 
of the urine, which, in the present case, were negative, as indeed they 
usually are in patients seen for the first time in convulsions or coma. 
The acetone and diacetic acid are not easily to be accounted for, as 
we have no evidence that the patient has been starving herself, and 
her vomiting is very recent. 

Subsequent examinations of the urine showed no sufficient evidence 
of renal disease. A trace of albumin and a few casts were present 
from time to time, but the amount and gravity of the urine were normal, 
and in my opinion it has been amply demonstrated that albumin and 
casts in a woman of this age are not in themselves evidence of renal 
disease, 1 although they are perfectly consistent with such a diagnosis, 
and do not in any way exclude it. 

Attacks of convulsions and coma in an elderly person whose heart 
shows some evidence of enlargement should always lead us to scrutinize 
the veins of the neck and to listen very carefully over the precordia 

1 F. C. Shattuck, Boston Med. and Surg. Jour., 1894, vol. cxxx, p. 613: " On the 
Urine of Persons over Fifty Years of Age." William Osier, New York Medical Jour., 
1901, lxxiv, p. 949: " On the Advantages of a Trace of Albumin and a few Tube-casts 
in the Urine of Certain Men Above Fifty Years of Age." 



FEVERS 



435 



for evidences of heart block (Adams-Stokes disease). In the present 
case no such evidence was forthcoming. 

Meningitis may begin as suddenly as this, with fever and convul- 
sions as the chief evidence of its presence. (See Case 266, p. 508.) 
Although there were no positive evidences of meningitis in this case, 
lumbar puncture was done, and a sterile fluid almost free from cells 
spurted out under considerable pressure. No micro-organisms could 
be demonstrated in the sediment. The very transient character of the 
leukocytosis is also evidence against any type of meningitis except that 
due to tuberculosis. 

Typhoid fever was difficult absolutely to exclude. The patient's 
age and the time of year, the initial leukocytosis and the convulsions — 
all were unusual and atypical, but none positively excluded the disease. 

Looking over the case as a whole, and taking account of the high 
blood-pressure, the absence of any focal symptoms and the intermit- 
tence of the cerebral manifestations, it seems to me that this case may 
best be classed as one of the group denominated by Pal as vascular 
crises x of the cerebral form. Pal's monograph (which does not seem 
to me to have received the attention which it deserves) describes in 
detail a large number of cases in which the diagnosis of cerebral hemor- 
rhage, embolism or thrombosis would ordinarily be made, yet in 
which the autopsy showed no gross organic lesion in the brain, no 
hemorrhage, softening or vascular occlusion. He shows that similar 
crises would reasonably be supposed to occur in cases of lead-poisoning 
(lead encephalopathy), in nephritis (transient uremic hemiplegia, 
aphasia, or amaurosis), as well as in arteriosclerotic cases with dimin- 
ished elasticity of the vessels and high blood-pressure. Presumably, 
as he argues, the colic of lead-poisoning, the gastric crises of tabes 
dorsalis, and many of the acute attacks of abdominal pain occurring 
without any other explanation in arteriosclerotics may be likewise 
explained as abdominal vascular crises, while the various forms of angina 
pectoris and of intermittent claudication may reasonably be considered 
as pectoral or peripheral crises of the same type. Vascular spasm is 
in all cases assumed as the fundamental change. 
Diagnosis.— -Vascular crisis. 

Case 230 
A girl three years old entered the hospital May 5, [908. The 

child was perfectly well until the day before, when vomiting, headache, 
and abdominal pain were complained of. Last night the vomiting 

'(,,;, knesen, J. Pal, Liepti< , [905 (S. Hii 



43 6 



DIFFERENTIAL DIAGNOSIS 



continued, although she took food well. The bowels were natural and 
there were no convulsions. 

Physical examination showed nothing wrong in the throat or ears, 
a normal heart, a slight dulness at the right apex extending down to 
the third rib in front and to the spine of the scapula behind. Over this 
area there was bronchial breathing and increased fremitus. 

The course of the temperature was as seen in the accompanying 
chart (Fig. 95). 

White count, 38,400 on May 5th; 50,000 on May 7th; 79,200 on 
May 13th; 69,000 on May 16th; 39,000 on May 18th; 23,000 on May 
20th; 17,000 on May 23d. 



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On the ninth of May the lower left lobe became likewise involved. 
On the eighteenth an aural consultant found double otitis media and 
opened both drums. On the twenty-second, though both ears were 
discharging freely, the temperature still remained high. Dulness and 
diminished breathing were then discovered at the right base. 

The child's general appearance was very poor. 

On the twenty-fourth the dulness and diminished respiration at the 
right base had increased, although there were no signs of anything 
abnormal in the front of the chest. A needle introduced into the back 
drew pus containing many extracellular pneumococci. A pure culture 
of pneumococci was obtained from this fluid. 



FEVERS 



437 



Discussion. — Obviously, this child's illness began with a pneu- 
monia, continued with a double otitis media, and ended with an 
empyema. The case is introduced mainly in order to call attention to 
the very typical chart, which exhibits, between the thirteenth and 
twenty-fourth, the variations which used to be interpreted as an un- 
resolved pneumonia, but which of late years have been shown to be 
practically always associated with a development of a postpneumonic 
empyema. 

The diagnosis of unresolved pneumonia was made at the Massa- 
chusetts General Hospital: n times from 1900 to 1905, 5 times from 
1905 to Oct., 1909. 

I feel quite convinced that the cases which I used to designate as 
" unresolved pneumonia " were all, or practically all, mistakes, the 
actual lesion being postpneumonic empyema. 

Outcome. — The chest was opened on the twenty-seventh and a 
large amount of pus evacuated, after which the temperature promptly 
fell to normal. The discharge ceased in three weeks. The week after 
this the wound was healed and the child went home well. 

Diagnosis. — Pneumonia and general pneumococcus infection. 

Case 231 

A laborer of twenty-four entered the hospital April 25, 1908. In 
June, 1907, he had had rheumatism for a week. Two weeks before 
the present illness he had had a bad sore throat. Ten days ago he 
began to have tenderness and pain in both knees and ankles, which 
compelled him to go to bed. Later, his hands, lips and shoulders 
became affected, the pain preventing sleep. During the past week he 
has had four nosebleeds. 

Physical examination showed that the tonsils were large and soft, 
but not red. Cardiac impulse extended to the fifth space, but did not 
pass the nipple. There was no enlargement to the right. The first 
sound was replaced by a murmur. The pulmonic second sound was 
reduplicated. The murmur was also heard in the axilla. Lungs and 
abdomen showed nothing abnormal. 

The joints of both hands, wrists, and the right knee and both ankles 
Swollen, hot, slightly reddened, and tender. 

White cells were 16.600. 

The course of the temperature is seen in the accompanying chart 
I 
On the second of May, under strontium salicylate, to grains every 

the patient seemed almost well, and was about ready to go home 



438 



DIFFERENTIAL DIAGNOSIS 



when a loud friction-rub, roughly synchronous with the heart's action, 
was heard along the left edge of the sternum, on the level of the fourth 
and fifth rib. There was no pain and no fever. The white cells were 
n,ooo. The friction-rub persisted for two weeks, but was never accom- 
panied by any pain. 

On the eighth of May he began to have considerable dyspnea, and 
crackling rales appeared at the right apex, in front, and throughout 
the whole left lung. He became rather cyanotic. His white cells rose 
to 29,000. 

On the ninth pain appeared in the right upper quadrant of the 
abdomen, together with rigidity and slight distention. Nothing could 
be made out on palpation. 




Fig. 96. — Chart of case 231. 



On the eighteenth of May the leukocytes were still 29,000. The 
patient was up in a chair a good deal of the time, and fairly comfortable, 
but slept little and did not seem to gain strength. The abdominal 
distention was very obstinate and difficult to overcome. His hands and 
feet began about this time to show considerable edema. From the 
twentieth of May he gained steadily, although his white cells remained 
high, and on the twenty-ninth of May were still 24,000. 

On the eighth of June his lungs were clear, the heart showed the 
murmur previously described, but no pericarditis. 

On the twelfth of June he had a second attack of sore throat. On 
the nineteenth his tonsils were removed, following which a whitish mem- 
brane formed over the stump. Nevertheless, he continued to improve, 
and on the twenty-fourth was discharged well. 



FEVERS 



439 



Discussion. — The sequence of events here may be summarized as 
follows: After a previous attack of acute arthritis the present illness 
begins with tonsillitis, which leads immediately to a second attack of 
arthritis associated with an equivocal cardiac murmur which may or 
may not be due to endocarditis. In May he develops a friction-rub, 
due, presumably, to pericardial exudate. Later we have edema of the 
lungs and cyanosis, due in all probability to an invasion of the myo- 
cardium by the same infectious agent which has already attacked the 
pericardium, and perhaps the endocardium (pancarditis). The ab- 
dominal symptoms lead us to conjecture that the gall-bladder may have 
become infected, or that a mild degree of peritonitis — such as often 
occurs as part of a general sepsis — may also be present. Finally, the 
illness winds up with a second attack of sore throat. 

We have here an excellent example of a septic infection due to some 
unknown but presumably attenuated type of pyogenic organism. One 
structure after another is attacked, yet the patient's resistance is such 
that he overcomes the invasion again and again, and may be left in 
the end nearly or quite as strong as he was in the beginning. In case he 
overcomes altogether this present attack, the chief danger is that the 
myocardium or the kidney will be permanently scarred, so that in 
later life a " chronic" myocarditis or nephritis will appear apparently 
out of a clear sky. In practice we often see this second chapter without 
the first, as the infection has been passed through without being desig- 
nated as anything more important than "the grip" or "a common cold." 

Diagnosis. — Sepsis. 

Case 232 

A stableman sixty-two years old entered the hospital February 10, 
1908. He has always been well. He denies venereal disease. His 
habits are good. For the past four or live days he has noticed fever 
and severe cough, with yellow sputa. This morning he began to have 
severe pain in the lower right chest, associated with shortness of breath, 
but was able to walk to the hospital. The course of his temperature 
en in the accompanying chart. 

Physical examination showed slight cyanosis; rapid, labored breath- 
ing; the right pupil larger than the left, and reacting sluggishly to light. 
The tongue came out somewhat to the right. There was well marked 
The heart's apex extended [} inches outside the nipple 
line in the fifth space; the righl border of dulness not made out; the 
heart v. as otherwise negative. The right lung was dull below the 
nipple line in the front and axilla, and up to a corresponding point in 



44Q 



DIFFERENTIAL DIAGNOSIS 



the back. Tactile and vocal fremitus were diminished. Breathing was 
bronchial, especially near the upper border of dulness. Many fine 
crackles were heard throughout both chests. 

The liver and other abdominal viscera were normal, though the belly- 
wall was held rather rigid. 

The sputa was mucopurulent. It contained no tubercle bacilli 
and very few pneumococci. 

The patient did not seem very sick, but was slightly delirious at 
night. 

On February 16th the physical signs and temperature were un- 
changed. The patient was alert, active, and did not seem to feel sick. 



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Fig. 97. — Chart of case 232. 



X-ray showed no evidence of pleural effusion. The sputa, repeatedly 
examined, showed nothing abnormal. 

On March 8th he was sitting up, but there was no change in the 
physical signs. 

On March 30th the dulness is perhaps a little less. There are no 
rales. He feels quite well, has no cough, and is discharged. 

Leukocytes: February nth, 17,800; February 14th, 19,400; February 
16th, 27,400; February 18th, 15,700; February 20th, 13,900; February 
22d, 31,100; February 25th, 14,700; February 29th, 24,200; March 
4th, 16,300; March 7th, 10,900; March nth, 11,400. 

Discussion. — This case is introduced chiefly on account of the re- 
markable temperature chart and the equivocal signs in the chest. The 



FEVERS 



441 



rapid, labored respiration, the cyanosis, the bronchial breathing, and 
the high initial fever are strongly suggestive of pneumonia, but it is 
very unusual to rind the vocal and tactile fremitus diminished over 
pneumonic solidification. 

The long duration of the fever, the absence of any rusty sputa, the 
moderate constitutional symptoms, and the signs at the base of the 
lung are very characteristic of a pleural effusion, serous or purulent; 
yet the x-ray, which usually shows a shadow corresponding to such 
an exudate, was negative at the time when the physical signs were 
exactly as above described. In view of the outcome of the case I do 
not see how we can make any other diagnosis than pleurisy, and in 
view of the negative v-ray examination it seems quite possible that we 
are dealing with a plastic exudate resulting finally in thickening from 
scar formation. 

Diagnosis. — Pleural effusion. 



Case 233 

A child of five entered the hospital May 20, 1908. His father had 
just had typhoid fever and his mother pneumonia. They are both at 
the Massachusetts Hospital. One 
sister is now having measles at 
the City Hospital. The child 
was perfectly well until last night, 
when he became feverish, lost 
his appetite, and at nine o'clock 
vomited. Since then he has been 
drowsy, with slight cough, and has 
vomited several times more. He 
complains of no pain anywhere. 

The course of the tempera- 
ture as seen in the accompany- 
ing chart (Fig. 98). 

Physical examination showed 
head, chest, and abdomen nega- 
tive. There was no rigidity of 
the neck; no Kernig's sign. 
There were many small red spots 
red over tin; trunk and limbs, 
not disappearing on pressure. 

The white cells were 51,000, with 88 per cent, polvnuclear 
'ative urine. 





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442 



DIFFERENTIAL DIAGNOSIS 



After entrance the child was drowsy and continued to vomit fre- 
quently and with great suddenness. On the twenty-first he became 
slightly delirious. 

Discussion. — In view of the other cases of fever in the family, one 
would naturally conjecture that this child has contracted either typhoid, 
measles, or pneumonia. The eruption is apparently hemorrhagic, 
not macular or papular, and this, with the absence of coryza, conjuncti- 
vitis, and Koplik's spots, is sufficient to exclude measles even at the 
outset, before the long course of the fever had shown us that some more 
serious infection must be at work. 

Typhoid may be unconditionally excluded by the presence of a high 
and continued leukocytosis. 

Of pneumonia there are no signs, though the herpes, the fever 
and leukocytosis suggest it. In children pneumonia is almost never 
"central," perhaps because it is easier to reach the depths of their lungs 
by the ordinary methods of physical examination. 

The vomiting and sluggishness, as well as the sudden onset, are 
rather characteristic of meningitis, but against this is the normal flexi- 
bility of the neck, the absence of any ham-string contractions and of 
any complaint of headache — all very constant symptoms. No further 
certainty can be arrived at without lumbar puncture. 

In all doubtful fevers occurring in young children one should in- 
vestigate the ear-drums, and, especially in girl babies, the urine, with 
reference to presence of pus and bacteria. In the present case the 
latter examination was made, not the former. We were thrown off 
our guard because the child did not complain of its ears, nor, indeed, 
of any pain, and because there was no discharge. 

Outcome. — Not until May 22d was there any evidence of rigidity 
in the neck. In the afternoon of the twenty-second lumbar puncture 
was done and 20 c.c. of turbid fluid obtained. In the sediment of this 
fluid 92 per cent, of polynuclear cells were found, and many Gram- 
negative diplococci were seen within and without the cells. Flexner's 
serum was injected, and the boy seemed brighter next day; but Kernig's 
sign was present on both sides, and slight internal strabismus had 
appeared. 

Herpes appeared upon the lips on the twenty-fourth. On the 
twenty-sixth he was taking nourishment freely, and wanted to sit up and 
go home. The neck was less rigid and strabismus gone; the pulse 
was of excellent quality, though rapid. 

The white count, May 23d, was 42,000; on the twenty-sixth, 21,000; 
on the twenty-eighth, 39,000. 



FEVERS 



443 



Lumbar puncture was done seven times more in the course of the 
next three weeks, and Flexner's serum repeatedly injected. The amount 
of fluid obtained was usually large — 35 to 40 c.c. 

The patient seemed to be doing well until the eighth of June, when 
be became rapidly worse and died. Autopsy showed meningitis, double 
otitis media, and a very large thymus. 

Diagnosis. — Epidemic meningitis. 

Case 234 

A child of six entered the hospital August 2, 1907. He has always 
been well until nine days ago, when he woke near midnight, feverish 
and vomiting. Five days ago his temperature was found to be 104 F. 
Four days ago it was 103 ° F. In the middle of the day he had less fever 
than at night. The last two nights he has slept fairly well. Before 
that he was rather restless. All the time his appetite has been good, 
but he has had only liquids. His bowels have been 
moved by cathartics and since the first he has had 
no vomiting, no nosebleed, no pain. He has lost 
considerably in weight. 

The course of the temperature as seen in the 
accompanying chart (Fig. 98). 

Physical examination was entirely negative; 
urine, normal. White cells, 15,000. No Widal 
reaction. 

By the eighth of August his temperature was 
normal and the child seemed perfectly well. The 
treatment consisted of laxatives and alcohol sponges. 

Discussion. — All general practitioners see many 
cases like the above. Ordinarily, they are spoken 
of as "grip" if they occur in winter, and as 
"indigestion" or "ptomain poisoning" if they 
occur in summer. Both these usages seem to me 
unfortunate, in that they tend to delay the prog- 
ress of medical knowledge. In the vast majority 
of cases there is not the slightest scientific warrant for either diagnosis. 
The bacteriologic or chemical evidence on which alone such diagnoses 

OOtdd be based is practically never secured, and the terms an- used 
mainly to satisfy the family. 

It seems to me much wiser, as well as more truthful, to state that 
in such a case we are dealing with an unknown infectious disease. 

p. 405. ) Ptomain poisoning is just now a very fashionable diagnosis, 



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444 



DIFFERENTIAL DIAGNOSIS 



and a phrase which the laity loves to brandish about. People are quite 
proud to have suffered from such an illness. But all this does not 
advance the progress of medicine, and tends in the long run to discredit 
our profession. 

I have seen similar fevers in which a Widal reaction was obtained, 
and to which, therefore, the term "abortive typhoid" was quite justifia- 
bly applied. If there is a pharyngitis, a tonsillitis, or a bronchitis, an 
inflammation of the frontal sinus, a jaundice, or a diarrhea, an infec- 
tion of the urinary passages or a subcutaneous abscess at any point, 
the fever may properly be considered as a manifestation of one of these 
local disturbances. In the absence of such it should, I think, be made 
clear primarily to ourselves and also to our patients that the disease 
has at present no name, and cannot be identified with any trouble 
previously known. 

Diagnosis. — Unknown infection. 



Case 235 

A school-boy of fourteen entered the hospital December 15, 1907. 
He has always previously been well. Four days ago he began to have 
pain in the right lower quadrant; it was not very 
severe, but has persisted to the present time. He 
vomited once the first day and twice the second day; 
he has been feverish throughout. He has had no cough, 
no sore throat and no pain except as above described. 
The bowels have moved every day. He was sent into 
the hospital with a diagnosis of appendicitis. At en- 
trance, there was slight tenderness in the right iliac 
fossa, but without any spasm. 

Rectal examination was negative; white count, 
20,000; Widal reaction negative. 

During the night the patient became slightly de- 
lirious and the temperature rose to 106.2 ° F. 

Physical examination showed at the right base slight 
dulness, slightly diminished tactile, slightly increased 
vocal, fremitus, and a few moist rales. Chest and 
abdomen were otherwise negative. The right knee- 
jerk could not be obtained; the left could be obtained 
only with difficulty. 
The patient was very delirious, quarreling with imaginary persons, 
and reaching out for objects in the air. There was no stiffness of the 





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of case 235. 



FEVERS 445 

neck, no Kernig's sign. The pupils have been markedly dilated through- 
out, but have been equal and reacted well to light. 

Discussion. — What infectious diseases are most common in boys 
of this age? 

(i) Pyogenic sepsis, with or without a focus in bone, joint, or heart 
valve. 

(2) Pneumococcous infections, with or without a demonstrable 
pneumonia. 

(3) Meningitis (otitic, epidemic, or tuberculous). 

(4) Typhoid. 

(5) Appendicitis. 

(6) Unknown infections. 

The latter are perhaps the commonest of all. 

Though the pain is referred to the right iliac fossa, the presence 
of a temperature of 106 F. and of an active delirium is distinctly 
against appendicitis. \\ e are on our guard also against the mistake, 
so common in patients of this age, of overlooking a pneumonia or a 
pleurisy because the abdominal pain often associated with these infec- 
tions in children occupies so prominent a place in the clinical picture. 

Meningitis might begin in this way, and the delirium and the absence 
of knee-jerks, together with the very high fever and leukocytosis, are 
quite consistent with that diagnosis. We are surprised, however, 
whenever we find meningitis without stiffness of the neck or Kernig's 
sign, especially if the patient is fourteen or younger, for these nervous 
manifestations are much more apt to be early and well marked in the 
fevers of children than in those of adults. Even meningeal irritation 
without actual meningitis often makes a child assume the posture of 
meningitis. The absence of headache, herpes, and eye changes is 
also somewhat against meningitis. Nevertheless, this disease can be 
ruled out only in case lumbar puncture shows no evidence of infection. 

A general septicemia, associated either with a pneumococcus or one 
of the varieties of streptococcus, is the next most reasonable hypothesis. 
Without blood culture one cannot get any greater certainty in this 
direction, but the signs in the lung, though in themselves slight, are 
sufficient to incline us toward a belief that a pneumococcous infection 
is present. It seems now to be quite clear that the existence or the 
e of lung consolidation is quite a secondary and accidental matter 
in infections due to the pneumococcus. We are dealing in all eases 
probably with a general infection carried by the blood. In the lung it 
no special reaction, may produce a slight bronchitis or 
bronchopneumonia, or may bring about the solidification of an entire 



446 



DIFFERENTIAL DIAGNOSIS 



lobe. But if all the pneumococcous infections were recognized and 
classified, we should probably find that those attended by a frank 
pneumonia are in the majority. 

Outcome. — The blood showed a pure culture of pneumococci. By 
the nineteenth signs of solidification were obvious at the right base. 
Lumbar puncture showed nothing. The child died on the same day 
on which solidification became obvious. 

Diagnosis. — Pneumonia. 

Case 236 

A carpenter of thirty-nine entered the hospital January 18, 1907. 
His family history is good. For the last three or four years he has 
had considerable cough in the morning, with greenish sputa. He 
denies venereal disease. He takes a pint of whisky three times a week. 
Three days ago he began to be chilly, stopped work and went to bed. 
Two days ago he began to have pain in the region of the heart and in 

the right axilla. To-day he has 
been spitting up reddish, frothy ma- 
terial. His cough has not kept him 
awake at night. The course of his 
temperature is seen in the accom- 
panying chart. 

Physical examination showed 
cyanosis, a negative heart, thick- 
ened arterial walls, many coarse 
and medium bubbles and squeaks 
throughout both lungs, diminished 
resonance in the lower right back 
and axilla. The upper part of the 
right front was hyperresonant, the 
lower part somewhat dull, with 
much-diminished breath-sounds and 
voice-sounds over the area between 
the third and fifth ribs. Abdomen 
negative. 

Over both lower legs there were many patches of brownish pigment 
from the size of a nickel to that of the palm of the hand; over the shins 
there were three white scars, two inches long, J